Informing patients in their golden years about potential end-of-life options through easy-to-understand videos, resulting in shared decision making, is at the core of Advanced Care Planning (ACP), whose Founders are Doctors Angelo Volandes and Aretha Delight Davis, who are also husband and wife.
Dr. Volandes spoke with TNH about ACP and his related book, The Conversation.
“For years as a physician,” says Volandes, who holds a MD from Yale and a MPH from Harvard, about why he wrote The Conversation, “I had been caring for seriously ill patients who were admitted to my hospital. Many of my patients with advanced illnesses were dying in the hospital, often tethered to machines and in pain. As I cared for them, I realized that none of their physicians were talking openly with them about their wishes for medical care and whether or not they wanted advanced life support interventions.
“The fact is most Americans prefer not to have aggressive medical procedures when they have an advanced illness,” Volandes emphasizes, “and the vast majority of Americans prefer to die at home in comfort and outside of the hospital. The book stems from my firm belief that although Americans receive some of the best health care money can buy, they also experience some of the worst deaths in the developed world. The primary reason we experience such horrible deaths is doctors’ failure to openly discuss medical care with seriously ill patients and to have The Conversation.
THE GREEK WAY
American-born to Greek parents – his father from Laconia and his mother from Chios – Volandes distinguishes between American and Greek end-of-life care for the elderly: “When it comes to dying and old age, there is a vast difference between the average family in the United States compared to the average family in Greece. In the United States, our society still pursues the denial of death and aging by searching for the next new thing in age regeneration or avoiding our ultimate fate, namely, death. I think this pervasive theme of avoiding death accounts for a good deal of why end-of-life care in this country is so poorly delivered.
“The average family in Greece has a very different understanding of the role of death and aging. I feel that there is a general acceptance in the cultural fabric in Greece of the fact that some day we will age and die. This stems directly from Socrates, who argued that philosophy is ultimately a preparation for death. What he meant by that is that death is inexorable and our stance towards that fact defines a good deal of our life. The average family in Greece does not avoid the issue of death and aging, but rather accepts the reality and embraces its fate.”
American doctors, Volandes says, approach medicine from a problem-solving perspective. They “like to tackle problems and fix them. And it is truly amazing what modern medicine has achieved in a relatively brief span of time. Can’t breathe? We can fix that with breathing machines. Have an infection in the blood? We can fix that with powerful antibiotics. The tougher issue, however, is when to recognize that the small fixes do not change the larger picture, to recognize that fixing specific problems may not fix the whole patient.
“This is medicine’s version of not seeing the forest for the trees. Doctors always search for the next fix, but we need to know when to use – or not use – our growing tool kit of fixes. If no one asks the critically ill patient whether or not he or she would even want these risky procedures that offer marginal benefits, if any, then doctors just keep on trying more interventions. Doctors need dial down the rapid pace of the modern industrial medical complex and sit down and talk with our patients.
Volandes has been immersed in his Greek heritage since childhood and shared some of those experiences that he says, helped him become a better doctor.
“Growing up in a working class immigrant family,” he begins, “my parents did not have the financial resources to send my siblings and me to Greece each summer. So my understanding of being Greek was formed mostly by my voracious reading of the Greek classics and the daily life of being a student in parochial school in Brooklyn, New York (A. Fantis Greek Orthodox School). However, I am most indebted to the Greek Government for giving me the opportunity to explore my culture, history and language. The Greek Ministry of Greeks Abroad, sponsored Greek youth abroad to visit their homeland, explore their history and language, and to instill an identity of Hellenism in the diaspora. I feel incredibly fortunate to have participated in the program, and am saddened by the reality that thousands of other young Greeks in the diaspora will not have this opportunity due to the financial crisis in Greece. I owe a great debt to Greek citizens for having given me this once-in-a-lifetime opportunity.
“I am often asked: what was the most important class that I took during college or medical school? Was it the chemistry class that was taught by a Nobel Laureate? Or was it the philosophy class taught by my thesis adviser, another Nobel prize winner? People are often shocked to learn that the most important class that I took was Modern Greek Language. Each semester during college, I took an additional class in Modern Greek so that I could speak Greek fluently. My hope was to someday return to my mother’s island of Chios and practice medicine in some capacity. During my medical training, I took six months off to shadow medical colleagues in the General Hospital of Chios.
“For six months, I followed some of the most dedicated medical doctors in the world. And they practiced under resource poor conditions, much like today. (My hospital back in the states had more CT scanners and other machines than all the surrounding islands combined.) But although they were resource poor, they were spiritually rich. Doctors were never rushed to discharge the next patient home, and often spent most of their time by the patient’s bedside to take the needed time to hear their story. When a CT scanner is not available to diagnose an illness, the patient’s story matters.
“But the most poignant experience was a graveyard shift in the Emergency Room. A colleague and I were called to come immediately to examine a newly admitted patient. He was one of the many illegal immigrants from bordering countries that swam their way to the island. The port police had picked him up and brought him to the hospital. He spoke neither Greek nor English. As we sat there and examined him, we took note of the infected scars on his back, likely from a large blade probably a machete. Although she had few supplies and could not speak his language, my colleague cleaned each of his wounds, cleaning them as best she could and applying much of the gauze that was in limited supply. At one point she turned to me and said, ‘Although we are poor and have little to offer, what we do have we share with others, regardless of who they are or where they are from.’
“I think about her statement often,” Volandes concludes, “years later as a senior physician and teacher of others. Had I never taken Modern Greek Language classes in college, there would have been little chance that I would have shadowed my Greek medical colleagues. Had I missed that experience, I would have been a much lesser doctor than I am today.”