The Conversation: A Revolutionary Plan for End-of-Life Care

Great book.

This book is part of what really is a revolutionary approach to health care as the end of life approaches -- treat the patient, not the disease. Doctor Volandes wants patients and their doctors to think about the health care they want when an illness reaches the point where a cure is unlikely. The way he wants patients to think about it is by learning what various alternative kinds of care entail, and by talking about what they want -- openly and honestly, with their loved ones and their doctors. Do they want medical professionals to "do anything"? Do that want some support of functions that are failing, but not the most drastic? Or do they want comfort care, in which everything possible is done to eliminate pain and discomfort, but in which drastic measures are not taken. If no decision is made, Dr. Volandes points out, the medical default is to do anything to keep the patient alive; that's what medical ethics call for unless the patient orders otherwise, and that's how the system works. Allowing this to happen, or in fact deciding to "do anything" often has nothing to do with treating the illness itself, but consists of treating the conditions that arise from it -- CPR when the heart stops, a ventilator when breathing fails, a feeding tube when the patient cannot eat. These may prolong life, but the quality of life that results can be miserable. For those who are already at that point, or who have loved ones at that point, these are decisions that need to be made, or the default will apply. Some may in fact choose the "do anything" option: that's their choice. But many others will choose not to accept drastic treatment, and will focus instead on care that keeps the comfortable. These are choices that need to be considered, and communicated clearly before a crisis arises. For those of us who are not ill, but who are getting on, these are also choices that should be considered and communicated. If nothing else, it can spare our loved ones a great deal of anguish when our time comes. Dr. Volandes way of doing this is what he calls "The conversation". He provides ways of approaching this, and he also talks about ways of communicating one's wishes once choices have been made -- living wills, health care proxies, and so on and so forth. This is a compassionate "how to" guide to making -- and communicating! -- choices that older people should make.

This book is an easy read and the case studies illustrated well how having a timely conversation can make the difference for all involved. Great examples for approach.

I gave the book to each of my (75+ years old) parents. They told me that they enjoyed the writing, found the message to be important and recommended “The Conversation” to their friends. I also led a book discussion group with older adults and caregivers of older adults, breaking the book chapters into the four sessions: Introduction & Chapter 1: The problem of end-of-life care in America; Chapters 2 & 3: Making decisions for others; Chapter 4: The Conversation; Chapters 5 & 6 & Afterword: A Solution. The book club members enjoyed the sessions and would recommend The Conversation “with confidence” to others. They felt that the book was “easy to read” and would be a “good gift — especially for someone who can’t initiate or who avoids the Conversation.” They said that the book was “very well written, engaging, motivating, important and life changing” noting that “Dr. Volandes offered perspective with humility” and that the “personal stories convey his personal growth and insight in a way that helps people understand.” Readers recognized The Conversation for helping to “clarify questions and encourage personal priorities” and for giving caregivers a better understanding of what it is like to have a serious illness. (“It helped me develop empathy for my father.” “The stories gave me a better understanding of situations.”) My takeaway is that The Conversation is a great book for book discussion groups. I foresee that I will be leading additional book discussions groups with The Conversation based on the success of this first session. These experiences recommend “The Conversation” as good and important read for patients, caregivers, and medical providers.

SOBERING FACT OF THE DAY: Life has a 100% mortality rate. Not 95%, not even 99.999%. Exactly 100%. We’re all gonna die. More imminently, all our parents are going to die. And chances are that this is not a topic you have discussed with them yet. The wise and generous Dr Angelo Volandes of Harvard has put this extraordinary book together to facilitate broaching the topic and planning for the inevitable with compassion, pragmatism and grace. Here’s a passage encapsulating the book’s mission: “Making sure that patients have discussions early and often and receive the type of health care they desire at the end of life is the only way to rectify the appalling misalignment of the type of medical care that people receive at the end of life and the type of medical care they truly desire, whether it is a full code, comfort care, or something in between. The health care system must make sure that the type of medical care patients receive at the end of life is consistent with their preferences.” Volandes includes links to his groundbreaking video illustrating the end-of-life choices between Life-Prolonging Care, Limited Medical Care, and Comfort Care, as well as a list of essential resources for end-of-life planning (eg Living Wills, Advance Directives and other forms). If you're over 40, you need to read this book for your parents -- *and* yourself, since you're not getting any younger either. Plan to discuss it at the first non-awkward opportunity that presents itself. Which will never come, so might as well do it now. The book is also a pleasure to read, illustrated with unforgettably poignant stories from Volandes' own patients (and parents!), as well as his own journey of growth as a doctor. Strong work, Dr Volandes, and thanks for your efforts on behalf of patients and their families. -- Ali Binazir, M.D., M.Phil., author of The Tao of Dating: The Smart Woman's Guide to Being Absolutely Irresistible