practicing medicine. “I could talk to the patient,” she recalls. “I
could in particular examine the patient really thoroughly and have
the time to go over all the labs, call the doctors he or she used to
have, get all the stu; and put the whole thing together. And when
I did that, I found a lot of times the initial diagnoses were wrong.
And the medications, most of these they didn’t need. And when I
took all those medications away and got the right diagnosis, the
patients got a whole lot better.”
Her main pitch, Sweet says, is to “put free time back into medicine.
“What’s really happening is that in the interest of being e;cient,
we made it impossible for doctors and nurses to fundamentally do
a good job,” she continues. “If you go to an internist or your regular
doctor, they’ve got something like 10 minutes to see you. And with
the 10 minutes, 7 of those minutes, they’ve now shown, are spent on
the computer. They’ve got three minutes to see you. You go in and
say, ‘My foot hurts,’ and they’ve got three minutes. So they spend one
minute talking to you and maybe one minute looking at the thing,
and one minute ordering your labs and your X-rays and your MRIs
and your medications, and you’re out.”
Sweet believes that insurance companies have made a costly miscalculation in limiting the time patients get with their primary
physicians — a mistake she traces back to health care economists
in the 1970s and their attempt to manage the high costs associated with physician care. Butler agrees that primary doctors
need more time with their patients, and says she’d like to see the
health care system move from its current emphasis on rewarding
procedures to rewarding time with patients. “I think all medicine
needs to move in the slow medicine direction, in the sense that
we should be lobbying to get internists paid triple what they’re
paid,” says Butler.
While changing pay scale would be one approach, another, sup-
ported by Butler and McCullough alike, is public education, such as
o;ering community college courses for caregivers.
“Dennis finally said, ‘ We’re not going to be able to change this
within the medical system,’;” recalls Butler of past discussions with
McCullough. “;‘ We’re going to be able to change it by educating consumers and essentially creating a movement from the outside that
pressures inward.’ And that’s my belief. It’s going to be baby-boom
women and men like me who become first dumbfounded, and then
to some degree outraged, and then finally informed as to exactly
what’s happened here.”
A Better Way
The final phrase in the title of Butler’s book — A Better Way of Death
— does not, for her, merely represent the idealized outcome of a
burgeoning movement. It represents Butler’s own reflections on
her mother’s death, and how it differed from that of her father.
A year after Jeffrey Butler’s memorial service, Katy Butler took
her mother to see a heart surgeon. Valerie was at the time aware
that she had two leaking heart valves, and she was considering her
cardiologist’s recommendation of open-heart surgery. After listen-
ing carefully to all that the heart surgeon had to say about survival
rates with and without the surgery and the risks associated with
the procedure — including the potential for cognitive decline — her
decision was made. She said no.
While Butler’s Times Magazine article focused primarily on her
father’s ordeal, Knocking on Heaven’s Door gives much more atten-
tion to her mother, including one particularly moving passage on
the temptation to second-guess after her mother’s passing.
It could have been too much self-administered morphine or too
little potassium. It could have been the stress of the cardiac cath-
eterization. It could have been getting up and making martinis
for the people who stopped by to see her. In the end, does it matter?
She died of old age, sickness and death. She died of a heart cal-
cified and broken by six years of nonstop caregiving. She died of
being eighty-four. She was continent and lucid to her end. She took
back her body from her doctors. She died the death she chose, not
the death they had in mind.
“ We act as though we have to pussyfoot and coddle people around
talking about the imminence of death. And I think people have more
inner resources than we really give them credit for,” says Butler
today. “I’m not saying these are easy conversations,” she adds — stopping short as she recalls those interactions with her mother. “She
was easy. She was easy because she was who she was, and she was so
blunt as a human being from day one any way. And like me, she was a
Buddhist, and so there’s a real highly held value about facing reality
as it is. And allowing change. And allowing loss.” M
; Katy Butler will read from Knocking on Heaven’s Door at Book Passage
in Corte Madera on September 11 at 7 p.m. and at Berkeley Arts &
Letters on September 12 at 7: 30 p.m.
; Victoria Sweet’s book God’s Hotel received the Gold Medal in nonfic-
tion at the 82nd Annual California Book Awards. It’s now available in
paperback at area bookstores and on Amazon.
; For additional personal perspectives on slow medicine and end-of-life
issues, see Michael Wolfe’s May 2012 piece “A Life Worth Ending: A
Son’s Plea to Let His Mother Go,” which appeared in New York magazine,
and Lisa Krieger’s San Jose Mercury News article “The Cost of Dying: It’s
Hard to Reject Care Even as Costs Soar,” which examined her father’s
“$323,000 ICU death” at Stanford Hospital.
; For an additional local perspective, visit slowmedicine.info — the
website of Dr. Ladd Bauer, a general practitioner and slow medicine
advocate based in Point Reyes Station. Bauer also runs a slow medicine–oriented practice, consulting with patients about particular health
problems and helping them find the best path forward. He can be
reached at firstname.lastname@example.org.;
; Both Marin General Hospital and Kaiser Permanente San Rafael
Medical Center place a strong emphasis on patient education.
Information on specific programs is available on their respective web-
sites, at maringeneral.org and kaiserpermanente.org.