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Atul Gawande explains the biggest problem with dying in America

"Letting Go" is a beautiful, difficult true story of death. You know from the very first sentence — "Sara Thomas Monopoli was pregnant with her first child when her doctors learned that she was going to die" — that it is going to be tragic.

This is a story that Atul Gawande wrote for The New Yorker in 2010, and its long been one of my favorite pieces of health care journalism because it grapples so starkly with the difficult realities of end-of-life care.

In the story, Monopoli is diagnosed with stage four lung cancer, a surprise for a non-smoking young woman. It's a devastating death sentence: doctors know that lung cancer that advanced is terminal.

Gawande knew this too — Monpoli was his patient. But actually discussing this fact with a young patient with a newborn baby seemed impossible.

"Having any sort of discussion where you begin to say, 'look you probably only have a few months to live. How do we make the best of that time without giving up on the options that you have?' That was a conversation I wasn't ready to have," Gawande recounts of the case in a new Frontline documentary that premiers tonight, Being Mortal, based on his recent book of the same title.

What's tragic about Monopoli's case was, of course, her death at an early age. But the tragedy that Gawande homes in on — the type of tragedy we talk about much less — is how terribly Monopoli's last days played out.

Her cancer essentially did not respond to the chemotherapy treatments she received. It spread to her abdomen and her thyroid. And this, Gawande argues, is the point where he and other doctors messed up.

Their mistake wasn't the fact that they didn't have the treatments to save Monopoli. It's the fact that they engaged in a sort of magical thinking, convincing themselves that they did — and conveying that fact to Monopoli and her family. This became starkly clear to me watching Gawande sit down with Monopoli's widow Rich in the Frontline documentary, and tell him that, in the course of Sarah's care, he told "a complete lie."

Here's the part of the transcript of that conversation that stuck with me the most:

Atul Gawande: When I came on the scene was when she got diagnosed with a second cancer. In my mind what I was thinking was I wouldn’t offer this surgery because the lung cancer is gonna take her life. And yet I didn’t 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. [Mutual laughter] And I know it was complete….

Rich Monopoli: Well you had joined us in our, in our sunny disposition, hoping for the best.

Atul Gawande: I knew, I knew it was not gonna, I mean I 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.

Rich Monopoli: I did not know it was an outright lie.

We’re all conditioned when the doctor comes out of the room and and takes the mask off and says, There’s nothing else we can do. In other words, I’ve thrown the kitchen sink at this patient and there’s nothing else I can do. That that’s….

Atul Gawande: That’s your image of what the day will be that comes?

Rich Monopoli: Correct.

Atul Gawande: But we always have something more we can do. That’s the problem.

This conversation is difficult to watch as a viewer, and I can only imagine its even more difficult in person. And, fair warning, the entire hour-long documentary doesn't get much easier. This is a documentary about people at the end-of-life, grappling with difficult decisions about how to handle the inevitable.

At the same time, for a documentary completely about death, Being Mortal does offer surprising solace, mostly in the story of a man named Jeff Shields, an elderly man with lymphoma. Chemotherapy hadn't worked for him; a bone marrow transplant was failing. Shields sees the hopes of his doctors ("In my experience, oncologists are always optimists," he says) but also the need to plan out the end of his life.

He wants to die on his farm, he tells his wife. He doesn't want to die in the hospital. This takes work; it takes a decision to move to hospice care, and stop treatment when treatment no longer appears to be working. It takes saying no to possible other treatments, the "always something more we can do" approach to medicine that Gawande derides.

This is what Shields does and his death, at least in the documentary, appears to be what he imagined. He's on a bed at his farm. He has conversations with his grandchildren about his death. The Frontline documentary interviewed Shields at a moment that turned out to be hours before his death. And what he says there is the description of a good death: not easy, or painless, but with support and love, surrounded by the people he cared about most.

"The last couple of weeks I've been surrounded by family and friends," Shields says. "It's been terrific. Some of the best days of life, I must say. But then there's a downward trend that's more rapid than I expected. I felt great during that time and my body was in rapid decline. Since then my mind has been in rapid decline. I get confused. But I'm still a happy guy."