Audiobooks Being Mortal: Medicine and What Matters in the EndAuthor Atul Gawande –

Medicine Has Triumphed In Modern Times, Transforming The Dangers Of Childbirth, Injury, And Disease From Harrowing To Manageable But When It Comes To The Inescapable Realities Of Aging And Death, What Medicine Can Do Often Runs Counter To What It ShouldThrough Eye Opening Research And Gripping Stories Of His Own Patients And Family, Atul Gawande, A Practicing Surgeon, Reveals The Suffering This Dynamic Has Produced Nursing Homes, Devoted Above All To Safety, Battle With Residents Over The Food They Are Allowed To Eat And The Choices They Are Allowed To Make Doctors, Uncomfortable Discussing Patients Anxieties About Death, Fall Back On False Hopes And Treatments That Are Actually Shortening Lives Instead Of Improving ThemIn His Bestselling Books, Gawande Has Fearlessly Revealed The Struggles Of His Profession Now He Examines Its Ultimate Limitations And Failures In His Own Practices As Well As Others As Life Draws To A Close Riveting, Honest, And Humane, Being Mortal Shows How The Ultimate Goal Is Not A Good Death But A Good Life All The Way To The Very End

10 thoughts on “Being Mortal: Medicine and What Matters in the End

  1. says:

    Added a link 4 18 15 at bottom In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality and created a new difficulty for mankind how to die Being Mortal 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 Old age is not a battle Old age is a massacre 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 Being Mortal is the distillation of what he learned Atul Gawande photo by Aubrey Calo From Gawande s siteWhat 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 M bius 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 hope is not a plan, and in fact we find from our trials that we are literally inflicting therapies on people that shorten their lives and increase their suffering, out of an inability to come to good decisions Gawande from the Frontline segmentPeople have priorities besides just living longer The percentage of the population that is elderly is rising dramatically as boomers enter their our golden 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 Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010Partly, this has to do with money incomes in geriatrics and adult primary care are among the lowest in medicine And partly, whether we admit it or not, a lot of doctors don t like taking care of the elderly 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 policy planners assumed that establishing a pension system would end poorhouses, but the problem did not go away In America, in the years following the passage of the Social Security Act of 1935, the number of elderly in poorhouses refused to drop States moved to close them but found they could not The reason old people wound up in poorhouses, it turned out, was not just that they didn t have money to pay for a home They were there because they d become too frail, sick, feeble, senile, or broken down to take care of themselves any, and they had nowhere else to turn for help Pensions provided a way of allowing the elderly to manage independently as long as possible in their retirement years But pensions hadn t provided a plan for that final, infirm stage of mortal life 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 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 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 erstwhile 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 Being Mortal 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 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 extensive list of must haves in order to make life worth living It does lead one to consider what your 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 Being Mortal 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 2014Review first posted 2 13 15 EXTRA STUFFLinks to the author s personal, Twitter and FB pagesThe book was the basis for a Frontline episode, which is excellentHere are the articles Gawande wrote as a New Yorker staff writerAn interview with Gawande from Modern Health Care Interview in Mother Jones magazine4 18 15 GR friend Vaidya sent along a link to a wonderful January 2015 NY Times opinion piece by Tim Kreider, You Are Going to Die, on facing what lies ahead Worth a look Thanks, V.5 3 15 An interesting Op Ed on futility careJanuary 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 Heroism of Incremental Care The title in the print magazine was Tell Me Where It Hurts

  2. says:

    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 detailed evaluations and descriptions of this book, I recommend to read the following reviews Will Byrnes s review s review s review DJ Wilson s review Foster s review s review Leaney s review s review Barker s review s review

  3. says:

    10 27 17 The most remarkable discussion of this book takes place between Atul Gawande and Kristin Tippett in the 10 26 17 podcast posted on the OnBeing website In the discussion we learn that Gawande went to medicine through politics 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 The only way death is not meaningless is to see yourself as part of something greater a family, a community, a society If you don t, mortality is only a horror 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 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 The Signature of All Things, 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 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, early 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 still 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 so before 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 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 Months later.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 quite right It is not mortality that is a horror if one is not part of a larger group It is life itself.

  4. says:

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

  5. says:

    If you re not afraid of dying, you re either lucky or lying.Meanwhile, this book gave me the heebee jeebees Did I really need to know that as I age my aorta will get crunchy and my shrinking brain will rattle around in my skull Or did I need to know and perhaps forever visualize the disgusting details of the downhill spiral of my teeth and feet, and what I ll have to show for them Don t worry, the author does not dwell on these things, but I do And, oh, how I hope I m not one of the 40% who is toothless by the time I m 85, if, of course, I live that long And do I even want to live that long after reading this depressing book Johnny Depp says he wants to be on a morphine drip and just drool and nod I m with him So actually, this book did help me figure out how I want to go out, if I get the choice.I guess going into this, I thought it would be a how to book, how to not be scared of dying Instead, I got a terrifying view of the horrors of nursing homes, terminal illness, aging, and deathbeds, and a blow by blow account of my bodily deterioration and decay It is not a pretty picture It is worse than my over active imagination can even conjure up Informative Yes, in spades And this doctor can write Clear, captivating prose I learned so much about how doctors and other caregivers think of and handle the elderly and terminal patients It talked about how people cling to hope even if their case is hopeless, and how doctors are often unable to tell it to them straight And about how doctors, despite their knowledge about the facts, often hold out hope for a miracle too Other good stuff Liked the many stories of people thriving in assisted living places The people were real, their stories fascinating in a quiet way The author is compassionate and has a conversational tone very undoctor like Liked learning about what hospice does exactly and about how much they can help out Liked that a provider had the bright idea to bring in other living things plants, dogs, and kids to assisted living places and loved hearing about how the residents responded so well.Stuff I didn t like Too much history about assisted living, and too many pioneers mentioned by name I get it that the author wants to give them credit, but we readers won t remember a single one Maybe some of this info would have better in an Acknowledgment section The author claims that people get mellow with age What Then why are so many old people on anti depressants and anti anxiety meds Stuff I wanted Wanted it to be psychological Wanted discussion about the fear of death, and a mention of how religion plays a part Wanted talk about the cost of medical care Does insurance always pay for chemo, for example Do families go bankrupt How much do finances affect the decision of whether to continue with treatment Wanted a secret formula for shooing away the fear of death and dying Funny, I was way comfortable reading about young people with terminal illnesses than about old people about to die I can handle reading about suffering that can t happen to me I m calmly empathetic But tell me about someone my age 65 or older who has just been diagnosed as terminal, and I squirm and twitch out of sight Just give me the clicker and let me watch Louis C.K., will you All fears and gripes aside, I know this is an important book, and it s an amazing one The doctor is talking about the elephant in the room, which is cathartic, depressing, and anxiety producing all at once you might want to have your valium handy I do think this book will be scary to read if you re in your 60s or older That is, unless you re lucky or lying.

  6. says:

    I read this book a fortnight ago, by my brother s bedside, at a time when both he and I knew he was dying Any book one reads in such a situation has to be absorbing, perceptive and worth the read This one was it was both relevant and pertinent I read it all We know less and less about our patients but and about science The author of Being Mortal Medicine and What Matters in the End is Atul Gawande He is an eminent American surgeon and author, who conducts research into public health issues A careful and sensitive analyst, Atul Gawande is often included in lists of top global thinkers He has delivered Reith Lectures, held the position of director of the World Health Organisation s effort to reduce surgical deaths, and been named a Fellow for his work in investigating and articulating modern surgical practices and medical ethics His background is partly American, partly Indian, as his parents both also doctors followed the Hindu religion The family were originally Marathi people from the Maharashtra region of India As a child however, Atul Gawande lived in Athens, Ohio, and studied at Stanford University, then read PPE Philosophy, Politics and Economics at Balliol College Oxford, and then did a further degree and Masters degree at Harvard Medical school Thus both his cultural and educational background provide a diversity of approaches and in depth knowledge for deciding issues of medical ethics.Near the very start of the book, Gawande points out that our ideas about death, and the desirability of both aging and the dying experience to be somehow controllable under a medical regime, is a very recent Western phenomenon In India and many other countries, for time immemorial, it has been accepted that an elderly person is valued and cared for by their family, for the whole of their life In the past surviving into old age was uncommon, and those who did survive served a special purpose as guardians of tradition, knowledge and history They tended to maintain their status and authority as heads of the household until death In many societies elders not only commanded respect and obedience but also led sacred rites and wielded political power This line of action is not therefore pursued with any sense of condescension, duty or even simple kindness by the young Rather it is just the way things are it is a tradition of respect Conversely to the modern Western ideal, the elderly held supreme power until they died, sometimes preventing younger family members from achieving what they wished, and perhaps resulting in great frustration But they were the wise elders, they held ultimate control Gawande gives an example of his grandfather, who rode around his property on horseback every day even after he was a hundred years old, to check that everything was in order A modern view would hold that this was a reckless and foolish activity for someone so frail Yet this tiny man in fragile health had all his mental faculties intact, and ruled his family in the same way he always had The difference in perceptions is startling, and also pertains to highly developed countries, Whereas today people often understate their age to census takers, studies of past censuses have revealed that they used to overstate it The dignity of old age was something to which everyone aspired Atul Gawande gives many such examples from his own childhood and early experience, plus a recent overview of how different countries have begun to change their perceptions, not always with good results Invariably, extending life through medicine is seen to be progress, and often implemented too quickly Scholars have identified the three stages of medical development which countries go through, which parallel their economic development In extreme poverty most deaths occur in the home, as people do not have access to any professional help As a country s economy improves and incomes rise, people begin to turn to health care systems and as a result often die in hospitals But in the third stage, when incomes rise to their highest levels, people have the ability to become interested in the quality of their lives, and ironically choose to die at home.Yet medical intervention and treatment so often gets stuck at the second stage This may result in people s actual choices being impaired, and decisions made without the full knowledge or understanding by all involved This theme is part of the main thrust of the book.The author also approaches this ethical conundrum from the other end He examines what has happened in recent years in the USA in particular, and how the medical establishment has completely monopolised the business of dying, to the extent that earlier long established ideas and principles common to all humans, are now never even considered He bravely cites himself as a culprit, detailing how it took him quite a few years as a practising surgeon, to begin to question whether he had the right to ride roughshod over other approaches to the question, What matters in the end How can we ensure that an individual really achieves what they want at the end of their life Had he made the cardinal error of surgeons that of being so committed to extending life, that he continued to carry out procedures that in actuality extended suffering, rather than enhancing life itself Atul Gawande gives both examples from his medical experience, plus many examples where he has investigated and interviewed those involved The text is heavy with anecdotes and stories which illustrate his points well, making extremely interesting and accessible reading It is not always easy to read this sorry catalogue of clinical and domestic details, however, despite Gawande s flowing prose So often the experts best intentions are frustrated So often people are provided with choices but not given the information which is most helpful So often people do not yet know the questions which they should ask those which would serve them best The legal phrase, the truth, the whole truth, and nothing but the truth springs to mind Clinicians, and those assessing care for the elderly, may well answer the questions posed But the answers, particularly those given by doctors, if not understood in their full context, often prove to be misleading and extremely damaging for the lifestyle of the person asking It is important to distinguish between person , and patient here Not everything can, or should, be fixed and made well We make it possible for them to make it home weaker and impaired, though They never return to their previous baseline We are human, not immortal Dying is a natural, inevitable consequent of living This sometimes tends to be forgotten For example, sometimes a person in their desire to be healthy, do not properly understand that a certain operation may be extremely difficult and painful, and that at best it can only provide temporary relief that they can never achieve the previous physical state which they desire the people who opt for these treatments aren t thinking a few added months They re thinking years They re thinking at least they re getting that lottery ticket s chance that their disease might not even be a problem any Ninety nine per cent understand they re dying, but one hundred per cent hope they re not They still want to beat their disease Some people may live longer without an operation If they are offered careful specialist help to make it the sort of life they would enjoy, they might possibly then choose this option Even if an operation can extend their life, the quality of life afterwards may not be fully explored, before a decision to commit to the operation is made In other cases the individuals are not elderly, but merely people who have serious enough conditions to be judged as close to the end of their life Or perhaps the people are elderly, but not suffering especially from any serious condition, but just gradually falling apart , as one doctor says Atul Gawande describes one resident of a care home, who displays a common feeling the elderly have, she didn t really want anyone to take care of her she just wanted to live a life of her own And those cheerful border guards had taken her keys and her passport With her home went her control How did we wind up in a world where the only choices for the old seem to be either going down with the volcano or yielding all control over our lives He carefully catalogues the development of various types of care homes and hospices, pointing out in which way they are successful, and how they can also be akin to prisons He observes, The sociologist Erving Goffman noted the likeness between prisons and nursing homes half a century ago in his book Asylums And in the current case study mentioned, All privacy and control were gone She was put in hospital clothes most of the time She woke when they told her, bathed and dressed when they told her, ate when they told her She lived with whomever they said she had to Such instances are often a result of legal rules a standardised demand to meet prescribed standards of hygiene and safety These are designed to protect the people in such care homes, but in fact only increase their institutionalisation, their feeling that they are living, A life designed to be safe but empty of anything they care about People denied individuality will either give in apathetically, or resist in any way they can, thereby risking appearing ridiculous to those in charge, Nursing home staff like, and approve of, residents who are fighters and show dignity and self esteem until these traits interfere with the staff s priorities for them Then they are feisty non cooperation refusing the scheduled activities or medications It s a favourite word for the aged The author also examines instances where elderly relatives live with their children, which often seems to be seen as a gold standard of care Yet even when this has been a mutually agreed wish on both sides, he shows that all too frequently it has not really worked out for any individuals involved Atul Gawande does not shy away from difficult issues He briefly enters the debate about assisted dying also termed assisted suicide or death with dignity which is legal in countries such as the Netherlands, Belgium and Switzerland, and certain states in the US such as Oregon, Washington and Vermont But by far the main part of this second half is concerned with the various ways of assisting people to have the old age they would themselves choose, whether in their own adapted home with help, or by moving to a wider community such as an assisted living facility, or something of an intermediate station between independent living and life in a nursing home He points out that it is a long road, there are costs to averting our eyes from the realities We put off dealing with the adaptations that we need to make as a society And we blind ourselves to the opportunities that exist to change the individual experience of aging for the better, And he charts all the progress made since the 1980 s when Keren Brown Wilson, who initially had the concept, first built her home for the aged in Oregon, where they could live with freedom and autonomy, however limited they became by their physical deterioration The key word in her mind was home Home is the one place where your own priorities hold sway People can t stop the aging of their bodies, but there are ways to make it manageable and to avert at least some of the worst effects The psychologist Laura Carstensen studied the emotional experiences of a large number of people from a variety of backgrounds and ages over many years She called her resulting hypothesis the socioemotional selectivity theory In essence this derives from the interesting conclusion that how we choose to spend our time depends on how much time we perceive ourselves to have When life s fragility is primed, people s goals and motives in their everyday lives shift completely It s perspective, not age, that matters most Once this has been taken on board, it becomes clear that nobody can accurately prescribe for another, which activities they will choose to follow in extreme old age Too often assumptions are made about what old people will like, and in each individual case, this may not be anywhere near the truth.In addition there is the temptation to over protect, Many of the things we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self My favourite anecdote from this book is that of Bill Thomas He was a working class boy who had surprised everybody by going to Harvard Medical school He worked as a doctor, but was also committed to a self sustaining lifestyle, growing his own food and using solar and wind power on his homestead He eventually accepted a position as head of a nursing home because he believed it would give him time to develop this side of his life, rather than continuing as an Accident and Emergency hospital doctor Yet he quickly identified the mistaken thinking behind any nursing home s regime, describing Three Plagues of nursing home existence boredom, loneliness and helplessness His solution, which succeeded beyond anyone s expectations, seems both ludicrous and frivolous in the extreme He introduced two dogs, four cats and a hundred parakeets into the home not gradually but all at once, in a chaotic mix where residents and staff alike had to think on their feet It is extraordinary that he ever managed to get the plans approved by the various authorities And it is even startling that the idea was such a phenomenal success He said to the author that, Habit and expectations had made institutional routines and safety greater priorities than living a good life and had prevented the nursing home from successfully bringing in even one dog to live with the residents Atul Gawande s description of the episode is a delight from start to finish, pointing up the human components throughout, the stupefaction, the clueless, bumbling incompetence, the lack of experience but ultimately the teamwork, laughter and joy in life which resulted from this simple ploy where someone just thought outside the box for a moment the effect on residents soon became impossible to ignore the residents began to wake up and come to life The lights turned back on in people s eyes There is a fundamental need in humans for a reason to live In the early 1970 s two psychologists, Judith Rodin and Ellen Langer did a study on the difference in a nursing home between residents who were given a plant to care for, and those who were not The difference was marked Even such a small responsibility as caring for a plant had a measurable difference in quality of life, with residents becoming active and alert and living longer the lesson seems almost Zen you live longer only when you stop trying to live longer Gawande concludes, Medicine s focus is narrow Medical professionals concentrate on repair of health, not sustenance of the soul He identifies the three types of doctor Isolating these types I could immediately assign doctors and surgeons of my own experience to the relevant category.The first is a paternalistic approach, where the doctor is a medical authority who is trying to ensure that the patient has the treatment which the doctor believes is the best for them This is a traditional approach, and there are still quite a few doctors around who act this way.The second is almost its opposite Atul Gawande terms it an informative approach The doctor tells the patient the facts and figures The rest is up to the patient to decide This is quite a common approach nowadays.The third approach is arguably by far the best In this the patient would have all the relevant information, but also much needed guidance This is termed an interpretative doctor patient relationship, or shared decision making The key is to determine what is important to the patient A good question for a doctor to ask would therefore be, What is important to you What are you most worried about When this is made explicit, the way forward to which facts and figures would be most helpful, and thus the way to proceed, may be a lot clearer I can personally remember instances where I have been happiest with medical matters, both for myself and for my loved ones, and in each case I would say that the professionals involved were using this interpretative technique.Much of this book is relevant, whatever country you are living in, although many of the examples given of hospices are those in the US There is ground breaking work being done in this area, particularly regarding assisted living and ways of assessing what people want and need at the end of their life It has to be said though, that as I was reading the book, I was heartily glad that I live in the UK, a country with at the moment a superlative health service I have to now qualify this statement, as many professionals involved make it abundantly clear that the service is crumbling Paramedics, nurses and doctors, have all relayed statistics to me recently which mean that on paper, with the current cutbacks, things just should not work Yet because of individuals compassion, dedication to the job, hard work and determination, they do, at the moment Things are on a knife edge.I was relieved that my brother was not a statistic in a book such as this That we with assistance from the professionals had been able to give him the ending to his life which, although it had come too early, was the one he desired He was able to spend some time in a hospice, a good one too, and from there be sent home to his wonderful sea view, and continue to have dedicated hospice care at home I was relieved that although he could take no food, and ultimately refused tube feed, the way he decided the end of his life was totally under his control At every stage he had the choice He was given oxygen, hydration and painkillers when required to relieve suffering All his care was extremely kind and respectful, and he died a dignified death According to everything I read in this book, we got it right My brother, after successful treatment for a virulent cancer, had been actively involved on the board of the Royal Marsden a famous London Cancer Hospital He had also been on the committee of the Royal College of Surgeons, before his final illness And when he saw me reading Being Mortal Medicine and What Matters in the End, knowing of the author s work, and at the tail end of his life with only days to live, he smilingly approved Atul Gawande is a caring, compassionate, respectful and intelligent person Long may he continue his reflections, research, investigations and continue writing these important books Courage is strength in the face of knowledge of what is to be feared or hoped Wisdom is prudent strength All we ask is to be allowed to remain the writers of our own story That story is ever changing Over the course of our lives, we may encounter unimaginable difficulties Our concerns and desires may shift But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties I hope to face the end calmly and in my own way.

  7. says:

    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 The chances that he would return to anything like the life he had even a few weeks earlier were zero But admitting this and helping him cope with it seemed beyond us We offered no acknowledgment or comfort or guidance We just had another treatment he could undergo Maybe something good would result We pay doctors give chemotherapy and to do surgery but not to take the time required to sort out when to do so is unwise This certainly is a factor But the issue isn t merely a matter of financing It arises from a still unresolved argument about what the function of medicine really is The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task Death is the enemy But the enemy has superior forces Eventually, it wins And in a war you cannot win, you don t want a general who fights to the point of total annihilation You don t want Custer You want Robert E Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can t, someone who understands that the damage is greatest if all you do is battle to the bitter end.In a set of brief chapters, Gawande adroitly covers innovations in making nursing homes 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 before succumbing to an associated lung cancer Of course I agree with the preacher of Ecclesiates that there is a time to love and a time to die and when my skein runs out I hope to face the end calmly and in my own way For most situations, however, I prefer the martial view that death is the ultimate enemy and I find nothing reproachable in those who rage mightily against the dying of the light What s wrong with looking for it Nothing, it seems to me, unless it means we have failed to prepare for the outcome that s vastly probable The trouble is that we ve built our medical system and culture around the long tail We ve created a multitrillion dollar edifice for dispensing the medical equivalent of lottery tickets and with only the rudiments of a system to prepare patients for the near certainty those tickets will not win Hope is not a plan, but hope is our plan.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 Whatever the limits and travails we face, we want to retain the autonomy the freedom to be the authors of our lives This is the very marrow of being human This is why the betrayals of body and mind that threaten to erase our character and memory remain among our most awful tortures The battle of being mortal is the battle to maintain the integrity of one s life to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be Sickness and old age make the struggle hard enough The professionals and institutions we turn to should not make it worse But we have at last entered an era in which an increasing number of them believe their job is not to confine people s choices, in the name of safety, but expand them, in the name of living a worthwhile life Most often, these days, medicine seems to supply neither Custers nor Lees We are increasingly the generals who march the soldiers onward, saying all the while, You let me know when you want to stop People die only once They have no experience to draw on They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come and escape a warehoused oblivion that few really want.

  8. says:

    Originally reviewed on the Night Owls Press blog here I was first introduced to Atul Gawande s writing in his Annals of Medicine column for The New Yorker magazine He wrote a thrilling piece about a woman with an itch an itch so strong, so persistent, it was beyond belief It stumped all of her doctors Medications didn t work MRIs and nerve tests revealed nothing conclusive One night, the woman woke up to fluid dripping down her face As if in some B horror movie, Gawande eventually reveals that she had scratched through bone, through her very own skull, into her brain Delving into neuroscience and how our brains work and the nature of perception, Gawande wrote a piece as compelling as a forensic thriller It wasn t just a dry reporting of medical cases and scientific findings Gawande quoted lines from Dante s Inferno It read like a story.Atul Gawande s Being Mortal Medicine and What Matters in the End is less an out and out thriller and a personal meditation on modern medicine and how it has treated illness, aging, and dying Being Mortal pulls back the veil on the institutions that treat the terminally ill and aging It is a clear eyed exploration of the sad business of dying and our bodies falling apart, taking us on a tour of gerontology, nursing homes, intensive care units, assisted living facilities, and multigenerational homes It is also a calm critique on medicine He writes Medical professionals concentrate on repair of health, not sustenance of the soul It s been an experiment in social engineering, putting our fates in the hands of people valued for their technical prowess than for their understanding of human needs Gawande s message The experiment has failed Twenty first century medicine can do miraculous things But in dealing with end of life issues, modern medicine has been dismal.Quality of life has been the most overlooked metric in medical treatments The measure of success for doctors is prolonging life, even if those extra days, weeks, months are miserable and and full of pain But according to Gawande it s not the fault of doctors or patients It s an entire culture we ve built up how we think of and treat the elderly, how everyone expects doctors to do everything it takes, to offer and try every medical procedure possible to slow down the inevitable And there is a lot to fear, too not just in the inevitable but in the choices we re given Gawande doesn t shy away from how this topic hits close to home His wife s grandmother and his own father are two people who are discussed intimately throughout the book He weaves the stories about their health and decline with the stories of other patients and colleagues.When describing how his own father struggled with the decision on whether to pursue radiation therapy for a tumor growing in his spine, Gawande dwells on the tough decisions that needed to be made His father had already undergone surgery to treat it, but things had taken a turn for the worse Should he pursue aggressive chemo, knowing the debilitating side effects that would happen It is a question that faces many families when they sit in the doctor s office and have to weigh the tradeoffs Having choices doesn t necessarily make it easier.At the heart of the book is a searching exploration of what the basic purpose of medicine really is What should we be paying doctors to do Gawande writes Death is the enemy But the enemy has superior forces Eventually, it wins And in a war that you cannot win, you don t want a general a doctor who fights to the point of total annihilation Fight to the bitter end sadly, that s what most people try to do.More and , as the population in the U.S gets older and as we live longer, we need doctors and nurses like Gawande who will broach discussion and say what they have seen, to tell people how death in a hospital really is, how aging really is, and prepare us for what s to come So what needs to be done Gawande suggests several things, and the message is clear We need of our institutions and medical practitioners to believe that we shouldn t limit people s choices in the name of safety but expand them, in the name of living a worthwhile life We see this in the later chapters when we meet enlightened practitioners and how they take a patient centric approach rather than a paternalistic one There is a wonderful anecdote that involves a colorful menagerie and an idealistic country doctor.While Gawande is critical and often frames his exploration of medicine in big socioeconomic and cultural terms, his arguments don t take sides He doesn t write to bully or polarize instead, he takes a deliberate, sometimes plodding middle road I sometimes wished he would be scathing of some of the atrocious experiences he hears about and even witnesses He doesn t loudly condemn bad decisions that were made in prescribing care or stripping away an elderly person s autonomy Instead, what he is good at is to acknowledge uncertainty and ambiguity All of us have underestimated the human element in medicine in some way An intense, thought provoking read that made me mindful about life and the march toward the inevitable Disclaimer I received an ARC of this book from the publisher for an honest and candid review This review was originally written for LibraryThing Early Reviewers.

  9. says:

    This is probably the most important book on mortality I ve ever read It is packed full of information and written in easily comprehendible language, in fact, very personal language There is so much information here I had a hard time reviewing as I want to share it all Promise, I won t, but will try to stay with just a few important highlights.First, this book looks at nursing homes and the rise and fall of assisted living You may think, what We have assisted living But, for a short time after people no longer simply died at home, assisted living, through the hard fought battles of one woman in particular was available to all patients Now the primary goal of safety has once again given us nursing homes Assisted living is mostly for those with the money to afford it This need for safety has left many to languish at places no different than former asylums This so called life is devoid of any purpose to live, and actually increases death rates.This book then goes into the medical profession The focus here is on repair, how to fix, what medications will work, when is surgery necessary The only problem is that the medical profession has no idea how to talk to people, and is even discouraged from doing so Most doctors have not had a single course in geriatrics What to do with an old person Amazing that we have no sense of our own mortality Now 25% of Medicare spending is for 5% in their final year of life, with very little benefit A great quote was We imagine that we can wait until doctors tell us there is nothing they can do, but rarely is there nothing that doctors can do So this instance of survival at all costs has left many to die in a hospital with tubes everywhere, fading in and out of awareness This of course leaves no chance for good byes, even I m sorry or I love you What it really comes down to is a few important questions I loved the ones provided in this book The biggest questions to ask are, what are your biggest fears or concerns What goals are most important to you and what trade offs are you willing to make, or not make Another topic was hospice I assumed hospice is only for the final end of life, but it is not Hospice is available at any time, and the focus is on a person s wants and needs Many get better after a stay, and leave, some even return to work Incredible book Atul Gawande is a physician who I believe has written a most timely and important book He provides an inside look at medicine, a historical perspective on dying, the most recent surveys on cost and care options and so much He comes from his own experiences and clearly his research has changed his own outlook on mortality A must read Highly recommended

  10. says:

    Depressing, but necessary to consider and talk about What s the one unfortunate thing everyone on this planet has in common right now We will all eventually die one day So knowing that eventuality, why do we not plan for and discuss how we want to spend our final years months weeks days If we are fortunate enough to go the way of a steady decline via old age, how can we maintain our enjoyment of life as we become less able to meet our own needs independently without burdening our loved ones If faced with a terminal prognosis, how do you weigh interventions that can possibly extend quantity of life versus those that can extend quality of life These questions and are covered in this book, with sobering real life examples, some of which come from the author s own family I found this book to be informative and hopefully useful at some point in the very distant future A must read for everyone, though perhaps delay doing so if there has been a recent death in your life, as this would probably be harder to read emotionally.