Our hospital staff holds monthly reviews of mortality and the care of patients at the end of life. For those deaths that so clearly come at the end of a long chronic illness, we ask ourselves how we could have done better. Over and over we see a pattern of shared denial — both patients and their caregivers seem to ignore the signs that life is slipping away. Why?
Well, human nature for one. We all thrive on hope. We humans, especially in Western societies, seem to think death is optional. We don’t like to face it, think about it, or plan for it. And medical professionals are trained to always look for the treatment we have missed, the breakthrough that will pull someone back from the brink. We have all experienced amazing recoveries in a few patients, so we tend to constantly strive to find that for everyone — it’s what our patients expect from us. It’s the thrill that we trained for — finding the cause of the symptom, zapping it with a drug or a surgical procedure or a radiation beam, and returning the person to full function.
However, there is good evidence that this optimism and constant search for another treatment make us lousy prognosticators. We typically overestimate a person’s life expectancy at the end of life. [There are plenty of egregious examples of the other error, but in aggregate we overestimate]. We hate to give in, we want to transmit hope.
And the sad reality is that the ‘silver bullet’ is really uncommon. Most of us will die of the gradual loss of functions associated with one or more chronic diseases. It’s not a hidden mysterious rare tumor that can be zapped into oblivion as often as it’s the accumulation of functional loss from diabetes, heart disease, chronic lung disease, or a common cancer we’ve had for a long time and is now back again. These chronic illnesses take away function in a stepwise fashion, and offer many tragic but welcome opportunities to discuss what an individual wants, and what a doctor can offer. Too often, these conversations don’t take place.
They are tough conversations — they are sad. Doctors assume patients notice their declining function and will ‘speak up’ when they have had enough. Patients can get used to declining function, and often assume that doctors can return them to previous levels of function after their disease acts up. This is actually uncommon.
Each of us defines the quality of life we want or will accept. And our thinking may evolve when we develop a severe illness. Care is ALWAYS centered on the patient’s choice. That choice, however, needs to be informed by the best medical facts available. And those facts need discussion before facing an urgent medical intervention.
As I have evolved my thinking about all this, I find that these discussions are easier each time. Patients usually welcome the opportunity to talk. I never know where the conversation will go, but for me, ‘taking care of someone’ means more than the right drug or surgical referral. It means helping people recognize futile care, and giving them a chance to think through what they want. Giving them a chance to cry about the unfairness of it all, to listen to those they love, even to ask for another medical opinion. It means really listening — and then following the direction the patient wants. That means sometimes doing more than I would have wanted to or sometimes stopping treatment before I am ready.
The reward is so clear, however, a deeper trust between doctor and patient. And for many at the end of life — the gift of the opportunity to make the choice to be at home, and stay there, with good plans for managing symptoms, and in the environment they want — around loved ones. That reward is the motivation for doctors and patients to find a way to speak up.
With acknowledgment to Daniel Callahan, and with apologies to all true philosophers, I have been thinking about what kind of life we lead, and how our choices influence that life. The conversation is one I have with myself (yes, just me in my head) and with the people that matter most to me — 
close friends, my wife, my kids. I have been thinking more about this lately because of two things — one is our enhanced recruiting effort at SVHC, the other is my annual fall trip in the wilderness with my closest friend. I’ll try to make the connection for you.
Of course we cannot choose everything about how life goes- life hands us challenges and surprises; tragedies and opportunities. That is when choice is so important. One who wrote it better than anyone else I’ve read is Victor Frankel in Man’s Search for Meaning. His thesis, distilled, is that we cannot chose what happens to us, but we can choose how we respond to it. He was interred in a concentration camp, but chose to be optimistic.
The only moment I can count on is this one, so I think I may as well make the most of it. Being angry, feeling victimized or worrying doesn’t fix anything and actually diminishes my appreciation of this moment. Also expressing those kinds of feelings certainly have some effects on others. Being with folks who are really angry, really anxious, or who really love to blame others for their woes can be tiresome.
So what’s the connection with recruiting and my wilderness experience? Well, as we have spent so much time reflecting on what we can offer doctors at our hospital, we have realized that most of the medical staff feels they have made a good choice about their life. They feel supported by their colleagues.. They feel satisfied that they are making a difference. 
They like the quality of life their kids have here — the education, the environment, the opportunities. We, as a medical staff, have not adequately ‘told our story.’ So we’re doing a better job now. We have a new website to help us with this. We don’t just look for great doctors; we tell them also what they will find here. We tell them what they can expect, and what they can contribute.
And the wilderness? That also is about reflection on “what kind of life?” How do I choose to spend my time? I choose to take my kids in the woods time after time, and as adults they still remember those times as the special ones, and one even goes out there himself- alone, with friends, or with me. I choose to spend four days a year in the woods with my best friend. We cherish the solitude, the peace, the opportunity to slow down. We get up with the sun and go to sleep when it goes down. I forget what day it is. A trio of curious river otters chatters at us and we laugh so hard we feel like we’re 10 years-old again.
So I am not a believer in fate at all. I think things happen, but we provide the ‘reason’. More important, we choose the response. Rise to it, interpret it, and take it someplace better. Choose what kind of life. It’s up to me.
As Bernard Shaw put it: “this is the true joy in life, the being used for a purpose recognized by yourself as a mighty one…the being a force of nature instead of a feverish selfish clod of ailments and grievances complaining that the world will not devote it self to making you happy.”