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.

  • Debbie

    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 af

    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 more they can do, but rarely is there nothing more 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 more. He comes from his own experiences and clearly his research has changed his own outlook on mortality. A must read. Highly recommended!

  • 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:

  • Bionic Jean

    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.

    The author of

    is Atul Gawande. He is an eminent American surgeon and author, who conducts research into public h

    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.

    The author of

    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.

    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,

    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,

    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 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.

    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,

    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 more akin to prisons. He observes,

    And in the current case study mentioned,

    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,

    People denied individuality will either give in apathetically, or resist in any way they can, thereby risking appearing ridiculous to those in charge,

    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

    He points out that it is a long road,

    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 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

    . 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.

    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,

    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 more 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

    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 more startling that the idea was such a phenomenal success. He said to the author that,

    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.

    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 more active and alert and living longer.

    Gawande concludes,

    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

    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

    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

    doctor-patient relationship, or

    . The key is to determine what is important to the patient. A good question for a doctor to ask would therefore be,

    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

    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

    , 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.

  • Genevieve

    * Originally reviewed on the Night Owls Press blog

    . *

    I was first introduced to

    's writing in his "Annals of Medicine" column for

    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 re

    * Originally reviewed on the Night Owls Press blog

    . *

    I was first introduced to

    's writing in his "Annals of Medicine" column for

    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

    . It read like a story.

    's

    is less an out-and-out thriller and more a personal meditation on modern medicine and how it has treated illness, aging, and dying.

    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 more 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 more 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 more 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 more, as the population in the U.S. gets older and as we live longer, we need more 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 more 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 more enlightened practitioners and how they take a more 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 more 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 more 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

    .]

  • Debbie

    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% (!

    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.

    -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.

    -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 more mellow with age. What? Then why are so many old people on anti-depressants and anti-anxiety meds?

    -Wanted it to be more psychological.

    -Wanted more 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 more 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.

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