Being Mortal: Medicine and What Matters in the End

Being Mortal: Medicine and What Matters in the End

In Being Mortal, bestselling author Atul Gawande tackles the hardest challenge of his profession: how medicine can not only improve life but also the process of its endingMedicine has triumphed in modern times, transforming birth, injury, and infectious disease from harrowing to manageable. But in the inevitable condition of aging and death, the goals of medicine seem too...

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Title:Being Mortal: Medicine and What Matters in the End
Author:Atul Gawande
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Edition Language:English

Being Mortal: Medicine and What Matters in the End Reviews

  • Trish

    10/27/17 The most remarkable discussion of this book takes place between Atul Gawande and Kristin Tippett in

    . In the discussion we learn that Gawande went to medicine through

    which may not surprise some of you. I had a radical insight as I listened: that doctors, by oath, are meant to provide life-giving care to rich and poor alike, without discrimination. Does that lead almost directly to the discussion about whether healthcare is a ri

    10/27/17 The most remarkable discussion of this book takes place between Atul Gawande and Kristin Tippett in

    . In the discussion we learn that Gawande went to medicine through

    which may not surprise some of you. I had a radical insight as I listened: that doctors, by oath, are meant to provide life-giving care to rich and poor alike, without discrimination. Does that lead almost directly to the discussion about whether healthcare is a right? You would think doctors, in that case, would be liberal to a person. That they are not means there is a skew in the process somewhere--possibly in the numbers of doctors the AMA allows to be certified.

    ------------------------------

    My great aunt lived to be 102 years old. She would often say, looking at the younger generations, "It’s wonderful to get old." Gawande touches on this in his memoir chronicling the death of his father and in his discussion of dying well. Older folks have more moments they classify as happy than do younger folks. Oldsters generally experience less anxiety, too, perhaps from having “seen it all before,” but perhaps also because they know bad times do pass. Usually.

    I still think my great aunt was being just a little facetious, since the rest of Gawande’s book tells us pretty explicitly that old age is not for wimps. In fact, as Elizabeth Gilbert suggested in her novel

    , we do better when we turn towards “the great changes that life brings” rather than turn our wills away. Gawande tells us how it is possible in some cases to choose less treatment rather than more when faced with life-threatening illness and experience a better quality of life in our final days.

    This is pretty grim stuff but Gawande is graceful, as graceful as he can be when the choices are so limited and so frankly horrible. When a loved one (or we ourselves) must make choices, it is wise, he counsels, to ask ourselves a few questions: What do we fear most? What do we want most to be able to do? What can/can’t we live without? What will we sacrifice so that we can accomplish what it is we want? Our choices may change as circumstances change, so one has to revisit occasionally, to make sure we (and our family and our doctors) are proceeding along the path we have chosen for ourselves.

    It is almost, but perhaps not quite, enough to make one wish for a sudden,

    death. We all must go through it, so we’re not alone. It’s just that medical knowledge, technology, and skill can do only so much, and after that we

    have to face the inevitable. Gawande gives lots of examples of patients and of people he has known who have these choices thrust upon them. On balance, he concludes, those who accept, rather than thoughtlessly fight, a terminal prognosis have a better death.

    This book is worth reading, maybe more so

    you need it. Filling out the hospital’s required “health care directive” is actually difficult unless you have someone like this to explain what it actually means. No intervention may mean weeks instead of months; it may also mean calm instead of recovering from radical surgery. It may just be unbearably depressing. I get that.

    One interesting study Gawande talks about is one in which people who know their time horizons are short, or who experience life-threatening conditions (e.g., living in a war zone, 9/11, surviving a tsunami) change their view of what they want out of life, their "hierarchy of needs" as defined by Maslow. People with unlimited horizons put a high premium on growth and meeting people who are interesting and influential. Those with foreshortened horizons look to their closest friends and family for sustenance and comfort. War zones may not grant you friends or family, but certainly intense, highly-charged, and memorable relationships result from them. Little is expected, much is granted. And I guess that is key. There is more generosity to go around when one is in the final days and it may be best not to occlude that blessing with a confusion of treatments that do not mean a better life.

    Gawande addresses some of the most difficult questions we have to decide in a lifetime. It is not easy to read. But it helps, I think, to know what choices we can make when the time comes for someone we love or for ourselves.

    ---------------------------------------------

    I have been thinking about the first quote I put at the beginning of my review since I read it. I wonder if that is not

    right. It is not mortality that is a horror if one is not part of a larger group. It is life itself.

  • Petra X

    This is brilliant. I'm having a good run of 5* books at the moment. Atul Gawande refers several times to

    so now I have to read that. I like it how one book leads to another sometimes.

  • Michael

    A clear, uplifting, and eloquent education on the deficiencies of the medical establishment in end-of-life care and promising progress toward improvements. This Boston surgeon has already authored accessible books on the human art behind the science of medicine with his “Complications” and “Better”. He is a master at using stories of his cases to address disparities between our expectations and the reality of medical practice and drawing on diverse research to advocate for needed changes. Here h

    A clear, uplifting, and eloquent education on the deficiencies of the medical establishment in end-of-life care and promising progress toward improvements. This Boston surgeon has already authored accessible books on the human art behind the science of medicine with his “Complications” and “Better”. He is a master at using stories of his cases to address disparities between our expectations and the reality of medical practice and drawing on diverse research to advocate for needed changes. Here he delves into the tragedy of so many people at the end of their life dying in the depersonalized, institutional conditions of hospitals and nursing homes.

    In in his own training he was taught to see death as the enemy to fight at every step with everything in the arsenal of medicine and didn’t conceive any role for doctors in facilitating help with the dying process. He does remember a seminar in which they read Tolstoy’s “The Death of Ivan Ilyich”, which highlighted the benefits the character gained from simple, humane interactions with his servant. But that lesson was soon forgotten. Only when some of his surgical interventions came to a bad end of complications and a miserable death in the ICU did he come to consider changing how he approached his cases. For one man with cancer invading the spinal cord, he successfully removed enough to delay the onset of paralysis, but he never recovered from the procedure. Such failures led the good doctor to rethink is ingrained approaches:

    In a set of brief chapters, Gawande adroitly covers innovations in making nursing homes more humane, the advent of assisted living solutions, and growth in palliative care and hospice services. Simple approaches like allowing nursing home residents have pets or opportunities to socialize with kids in a nearby afterschool program had surprisingly powerful benefits. The power of assisted living programs to preserve privacy and autonomy while fostering socialization and sense of community is illustrated with exemplary stories. From a low point of just 17% of people dying at home in the 80’s, by 2010 fully 40% were being supported at the end through hospice care, of which half involved a home location. Studies revealed that patients who stopped chemo sooner and entered hospice sooner had less suffering at the end and lived up to 25% longer. The outcome had Zen aspect in that “you live longer only when you stop trying to live longer”. Just family communication about end of life care decisions by palliative care providers had a huge impact on reducing costly ER and ICU utilization.

    The lesson the Gawande learned and began applying to his patients (and the situation of his own father) was to take the time to find out what gives the person a sense of meaning and purpose in life and to explore the trade-offs they are willing to make to best fulfill those goals relative to the risks of procedures aimed at giving them a longer life. But the challenge remains in every case to guide his patients on when to stop the pursuit of treatment in favor concentrating on living the best they can with what they have left. The case of a hero of mine, biologist Stephen Jay Gould, facing a fatal lung disease, mesothelioma, is telling. In an essay “The Median Isn’t the Message” he notes how variation around the median survival of 8 months included a long tail of minority cases with longer survival, a situation luck placed him with (he lived 20 years more before succumbing to an associated lung cancer):

    After exploring the insights of social scientists such as Goffman, Maslow, and Dworkin, he arrives at some important concepts that providers and families of the seriously ill should keep foremost in mind:

  • Will Byrnes

    (Added a link - 4/18/15 - at bottom)

    is completely irrelevant for any readers who do not have elderly relations, do not know anyone who is old or in failing health, and do not themselves expect to become old. Otherwise, this is must-read stuff. Life may be a journey, but all our roads, however long

    (Added a link - 4/18/15 - at bottom)

    is completely irrelevant for any readers who do not have elderly relations, do not know anyone who is old or in failing health, and do not themselves expect to become old. Otherwise, this is must-read stuff. Life may be a journey, but all our roads, however long or short, whether express, local or HOV, whether traversed by foot, burro, bus, SUV, monster truck or Star Trek transporter, converge on the same destination, and the quality of those last few miles is something we should all be concerned about.

    Atul Gawande, as a doctor, has had considerable exposure to issues of death and dying, but when his father was diagnosed with brain cancer, Gawande was motivated to look into how end of life care was being handled across the board.

    is the distillation of what he learned.

    - photo by Aubrey Calo – From Gawande’s site

    What we have today is the medicalization of old age. It has not always been thus. Instead of embracing the circle of life, we have bent and twisted it until it looks like a Möbius strip. Facing the fact that we are all going to die is certainly not a fun notion, but neither is believing we can extend our so-called lives indefinitely. There really is such a thing as quality of life, and probably should be a thing called quality of death as well.

    People have priorities besides just living longer.

    The percentage of the population that is elderly is rising dramatically as boomers enter their (our)

    years. So how is the medical profession preparing to meet the booming demand for geriatric care? With the same gusto as a Republican legislature faced with a crumbling infrastructure. They are cutting back. I picture a cinematic bandit with a white coat under his bandolier, "We doan need no steenking geriatricians." The reality is not far from this.

    Gawande tracks the history of late-life care from the poorhouse to the hospital to the nursing home to the range of options currently available, providing information of the benefits and shortfalls of each. Assisted care comes in for a lot of attention.

    There comes a point at which one passes from being elderly to being frail and the range of options narrows. Gawande asks, “What does it mean to be good at taking care of people whose problems we cannot fix?” When does the need for safety leap past a person’s need for independence? There are various levels of care offered at different sorts of facilities. Some people can remain at home for a long time if they have a bit of help. Nursing homes are heavily medical, assisted care facilities more independence oriented. And there are plenty of variations on each. Gawande looks at several variations on assisted living facilities, noting the strengths and weaknesses. I found this extremely interesting. He also looks at some techniques that can make assisted living more tolerable, adding flora and fauna for residents to take care of for example, things like different sorts of physical layouts. One of these reminded me very much of my daughter’s college dorm setup. Point being that there is a spectrum and beginning from understanding the patient/resident needs and desires in the context of physical and medical limitations can inform the choices to be made. All too often these decisions are made without considering the impact on or getting input from the person most affected.

    looks at trends in the impact of using all available means to keep people alive, and how that affects someone’s final days. When is the right time to stop treatment? How much is too much? When is the right time to die? It used to be that, when it was time, one’s final days were spent at home, with family. These days, they are likelier to be spent in an institution of some sort, and as likely as not, entail the patient being hooked up to sundry tubes, wires and flashing, beeping devices. It is important to identify exactly what it is that a person wants, or fears most, as a basis for decision-making. If your needs are minimal it speaks to one set of decisions. If your needs are more substantial, it speaks to another. One person said that as long as he could watch football and eat chocolate ice cream, life would be worth living. (There is no way he is a Jets fan) Others have a more extensive list of must-haves in order to make life worth living. It does lead one to consider what

    list might include. For me, watching baseball would definitely figure in. Being able to read and write, to communicate would be necessary. What if you couldn't clean yourself? What if you could only have food through tubes? How much pain could you live with, and what measures would be acceptable to ameliorate it? What would keeping me alive cost? And how much is too much? All these questions figure into deciding the appropriate level of care. One fascinating section here had to do with hospice care, which need not take place in a hospice building. That was news to me. And it is a revelation how such care impacts patients.

    One of the significant points of the book is that planning is paramount. Have those difficult conversations. Talk about what you want for yourself, if your care is at issue, or what your parent/friend/spouse/relation wants well before one is in a crisis situation. It may be uncomfortable, but it is hugely important. In fact, this book is hugely important.

    offers not just a fascinating look at the history of late life care and living options, it not only offers a review of what is happening out there in the field of facilities for the frail and in the theories of how to approach late life care, it not only offers sage advice on planning for eventualities that we must all face sooner or later, it does all these things with humor and clarity, the bookish equivalent of an excellent bed-side manner. It is a fast read, too, useful if time is short. I would strongly suggest adding Gawande’s book to your bucket list, before…you know… it gets kicked. This is must-read stuff.

    Published – 10/7/2014

    Review Posted – 2/13/15

    =============================

    Links to the author’s

    ,

    and

    pages

    The book was the basis for a

    episode, which is excellent

    Here are the

    as a New Yorker staff writer

    An interview with Gawande from

    Interview in

    magazine

    4/18/15 - GR friend

    sent along a link to a wonderful January 2015 NY Times opinion piece by Tim Kreider,

    , on facing what lies ahead. Worth a look. Thanks, V.

    5/3/15 - An interesting Op-Ed on

    January 23, 2017 - The New Yorker Magazine - Gawande article on the benefits of investment in incremental care in light of investments in heroic intervention - interesting stuff -

    (The title in the print magazine was

    )

  • Lilo

    This is going to be a very short review. I just simply say:

    If you think you might get older as time goes by and/or think you might even die at some time (or have relatives or other loved ones to whom this might apply), I urge you to read this book. And if you happen to be over 50 (or care about someone over 50), read this book now.--You heard me. I said NOW!

    For more detailed evaluations and descriptions of this book, I recommend to read the following reviews:

    Will Byrnes's review:

    This is going to be a very short review. I just simply say:

    If you think you might get older as time goes by and/or think you might even die at some time (or have relatives or other loved ones to whom this might apply), I urge you to read this book. And if you happen to be over 50 (or care about someone over 50), read this book now.--You heard me. I said NOW!

    For more detailed evaluations and descriptions of this book, I recommend to read the following reviews:

    Will Byrnes's review:

    Cheryl's review:

    Michael's review:

    Debbie "DJ" Wilson's review:

    Rebecca Foster's review:

    Elyse's review:

    Laura Leaney's review:

    Correen's review:

    James Barker's review:

    HBalikov's review:

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