Hope for a Cool Pillow by Margaret Overton

Many end-of-life discussions have been popular these past couple years, but this one is a little different. It comes at the discussion from a different angle, and it is an angle I have not seen well-articulated, certainly not by a doctor.

For one thing, it is intensely personal, especially in the beginning. Overton claims to be an introvert, but she does an awful a lot of reaching out in this book. I laughed aloud at one joke she told on herself:

At her nursery school, they often played musical chairs, “which I loathed and which may have scarred me for life. I still worry about adequate seating. Usually some poor kid who was not paying attention got stuck without a chair. Then he stood awkwardly and felt blazingly stupid while everyone else sat comfortably and looked smug. It was a terrible game.”

It is hard not to like this woman flinching yet at a child’s game. But, in a way, this book is about paying attention so you can lie as comfortably as possible on your own deathbed.

As a doctor, Overton has the viewpoint, motives, and reaction to incentives of a doctor. But here she is talking about the health care system and why it doesn’t seem to work for everyone (according to statistics, we might say anyone) in this country. I have never personally seen a doctor question in detail the incentives of the system, but Overton does here. She is very thought-provoking, particularly because she doesn’t give us easy answers. She acknowledges the questions, and asks us to do the same.

”The last six months of life accounted for roughly twenty-five percent of our Medicare spending….We try really hard to revive the people least likely to benefit….doctors often operate to fix something that will not save a dying patient, and in doing so avoid the difficult conversation with patients and caregivers about their prognosis and what they want.”

So, it is not so different from Atul Gawande’s Being Mortal, except that she gives a little responsibility to doctors, many of whom are not trained nor equipped for this conversation.

If a person with good health insurance and a terminal disease is in the hospital, is there any reason to limit treatment? She suggests that a for-profit private system of healthcare may not give us the kind of incentives, treatments, and quality of life (or quality of death) we desire.

”I find the concept of for-profit hospitals appalling. There’s an inherent misalignment of motives in the “business” of medicine. Physicians have a moral and financial incentive to provide excessive care to people who can pay for it as long as they have a heartbeat.”

She interleaves her narrative about taking a three-part post-graduate course at Harvard on hospital administration with the declining health of her father and her mother, and with experiences she is having in the hospital. Mostly she wants to share her grief, her expertise, her thinking, and her care. She seems the best kind of friend to talk with about end-of-life issues.

Her father had urged on her the need for preparation, and attention to these matters. He managed very well, until his cancer diagnosis. After many treatments meant to extend his life rather than cure his cancer, things got grimmer. He decided he’d had enough, and his preparation meant his family did not have a hard time of it.

Overton’s mother was a different story, and many of you will recognize the more lingering death of a dementia patient. However, even this wasn’t as painful as some of us experience, due to that planning again. The real problem comes when someone has no family to help, as is the case with many patients Overton sees in the hospital at the last stages of their lives, treated callously by an ever-changing roster of medical care personnel, and unable to make clear decisions.

I find it fruitful to hear the experiences of a doctor, and note she says “Personally, I don’t want to live into my nineties.” Her recommendation is that we do not wait on thinking about these things because life is fragile, and you don’t want to be one of the 45% of patients without advanced directives. Your life, in that case, would no longer be your own.

Totally inappropriately, I am adding a note that Overton introduced me to the Dunning-Kruger effect, which is something I thought I'd invented, frankly. It is the notion that incompetent folks may be too incompetent to know how incompetent they are. It is a very useful construct, particularly in these times.


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