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Medicine 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 frequently to run counter to the interest of the human spirit. Nursing homes, preoccupied with safety, pin patients into railed beds and wheelchairs. Hospitals isolate the dying, checking for vital signs long after the goals of cure have become moot. Doctors, committed to extending life, continue to carry out devastating procedures that in the end extend suffering. Gawande, a practicing surgeon, addresses his profession's ultimate limitation, arguing that quality of life is the desired goal for patients and families. Gawande offers examples of freer, more socially fulfilling models for assisting the infirm and dependent elderly, and he explores the varieties of hospice care to demonstrate that a person's last weeks or months may be rich and dignified.… (more)
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Gawande uses his experiences with the terminally ill as a medical student, surgeon, independent observer and son to effectively illuminate the points he makes and the lessons he has learned, which transforms [Being Mortal] from a dry treatise with limited usefulness to a valuable and necessary work that individuals, families, health care providers and policy makers will benefit from and easily relate to. He allows the afflicted and those who work with and care for them to share their stories as well, which provides the reader with more insight and clarity.
One of the most important lessons for physicians in Being Mortal, and the one that had the greatest impact on me as a hospital based pediatrician who routinely cares for incurably and terminally ill children, came to Gawande from the individuals and medical staff that he interviewed and the literature that he read in order to write this book. Too often the focus of the care of the dying is on what medicine can do for the patient: surgeons can operate to remove or debulk a tumor, oncologists can try yet another chemotherapeutic agent when others have failed, and hospitalists and intensivists can provide antibiotics, oxygen and other supportive measures to manage a current crisis. Unfortunately, these interventions frequently do not reverse or improve the primary illness, and the patient is either left in a more debilitated state than he was before, suffers from severe side effects from these treatments that can be worse than the illness itself, or both. Instead, the focus should be on what the patient wants in his remaining days instead of an all out, scorched earth effort to achieve a cure, and how his medical team and loved ones can help him achieve his goals and make him comfortable and lucid as the end nears. Only by asking and listening to the patients and family will this information be learned, and in doing so the physicians and other medical staff can provide the services that are most needed.
As a physician, a son of elderly parents, and a person contemplating his own mortality in middle age, I found this to be one of the most important books I have ever read, and it is one that I will turn to time and again to remember the wisdom contained within it. Being Mortal should be read by everyone, and I thank Dr. Gawande for sharing his own experiences, failures and successes with us in writing this essential work.
It is incredibly well written, well researched and very thought provoking. As a surgeon and physician Gawande covers quite a few topics, including end of life issues,
Some of the comments were those I could relate to, including the fact that this time when I had surgery, a number of the nurses and doctors called me "honey!" This made me realize that society is looking at a 62 year old and thinking I am old! I don't think of myself as old, but I do know I am the generation of the baby boomers, and we are the ones that are starting to impact on health care and insurance coverage costs. One of the head surgeons looked at me and said, "Hey, you are 62, but you don't look old!" His tonal comment indicated that he perceives 62 to be someone who is elderly.
And, as a friend one said, we will probably be the first generation to be buried without our original body parts. We have knee and hip replacements, teeth with fillings, and in my case, three neck fusions and now rods and screws throughout my entire spine. Luckily, I'm young enough to make the decisions regarding difficult surgeries. But, as the author stresses, many as they grow "OLD" might not have that luxury, ie either a health care system or family will make the decisions for them.
Of particular interest was the author's research which indicates that fewer people are studying geriatrics, or choosing to work with the elderly. Already there is a shortage of doctors in this field, primarily dictated by the fact that the elderly take much more time during an office visit, and this is time insurance companies are not readily agreeing to reimburse.
If then we look to the future, knowing that already there is a shortage in these fields, what will happen to the baby boomer generation, now living longer?
The author is very frank about our rights at the end of our lives to make clear decisions regarding what we want to do should we be in a situation such as end-stage cancer and the fact that conversations need to occur openly, honestly and to listen to the one who is dying and to respect their wishes.
Is chemo worth the time it robs from living our last days? Does the one riddled and ravaged with cancer have the right to say no to chemo and to be heavily medicated instead? Can the family allow the grace to respect wishes? Can doctors who are trained to heal at all costs be re-trained to be able to have frank conversations with their patients regarding prognosis, risks and choices? Can we as a society have a sea change in the way in which we look at the end of our days and be clear regarding how we want to live them.
There are chapters regarding assisted living homes and lots of information regarding what concepts work for the elderly, such as individual rooms and pets at the facilities opposed to having a stranger for a room mate, separated by a sheer curtain, when all your possessions are now on a shelf in a closet. It made me realize that I find tremendous comfort in my books stacked throughout the house and the feelings I would have if I could no longer have them.
This is an incredible, very thought-provoking book. I highly recommend. While it deals with very heavy issues, I did not find it depressing. Rather, I found it an incredible, honest look at the natural aging process and the right to live with respect.
Dr. Gawande also examines the role of medicine for patients near the end of their lives. He emphasizes that doctors should find out what terminally ill persons want instead of doing heroic measures which may keep the people alive longer but often in great pain with a poor quality of life. He discusses the different approaches doctors use, and advocates that doctors work with patients and their families work to determine the proper treatment for the patient to live as fully as that person can. Although the emphasis is on the elderly, one of the many stories told as examples concerns a young, newly married woman who has her baby after becoming terminally ill.
This review is based on the advance reader’s edition and does not include the acknowledgments or index, and the endnotes are not numbered nor are their presence indicated in the text.
The first conflict is between the way in which we conceive of the role of the physician and the needs of the elderly. The physician is understand and trained as an expert on the mechanisms of the body, and not of the value-based decisions that are involved in end of life care. After all, the argument goes, values are deeply personal, and physicians cannot be experts in them. Yet, Gawande argues, this merely leads us to train our physicians and arrange our medical institutions to aim at the extension of life even at the expense of these other values. The physician is focused on the patient's condition as a problem, and not on relating to the patient. The care that results, he argues, is not responsive to the situations or needs of the dying.
The second is between the role death plays in our lives and the ignorance with which we approach it. We are unable and unwilling to have conversations about what life we would like to lead as we enter our final stages, and when we would like to die. The result is that we are ignorant, not of our medical conditions, but of our own values. We do not know, and our caregivers do not know, what care will actually respond to our needs and desires, since they do not even know our needs and desires.
The two combine in powerful ways, for the lack of communication between physicians and their patients underlies and exacerbates patient ignorance. Similarly, the expectations that power of modern medicine places on the family and friends of the dying similarly constrains those at the end of their life. They have no direction to turn to have these deeply difficult and important conversations about what we want the end of our lives, and our deaths, to look like. This, in turn, leads us to pursue means that prolong life without careful consideration of what we are prolonging. This fuels the dominant physician model, and the problems are deepened.
With Gawande's background as a physician, his insightful consideration of philosophical questions and his clear writing style, I found this to be a delightful meditation on these abstract questions about the ways in which we understand physicians and their role in providing care. It raises a number of fascinating questions, and explores them in sophisticated ways without sacrificing readability. I would use the book, or portions of it, in one of my Bioethics, or applied ethics classes.
It is also deeply moving with a personal touch that helps the reader engage with the text in not merely a philosophical/medical/social way, but in a deeply personal way. Gawande deftly weaves personal stories throughout each chapter, unveiling the central stories of each bit by bit as they fit the theme of the chapter. Thinking over these cases naturally led me to reflect on the people I know and care about, and about myself.
I found this to be a sophisticated and powerful book, but one that is by no means dry, stuffy or difficult to read. Gawande's prose is easy to read, and the ideas are presented in such a way that he is leading the reader to think through the deep issues. I highly recommend this book for any reader who will one day face the decisions of death and dying - and it should be obvious by this that I am extending this recommendation widely indeed.
I've never given much thought prior to reading this book, about palliative care, hospices, assisted and independence living options that could and should provide people with a less stressful path to the end of their earth-bound lives. I'd not given any thought to how and what I might possibly want if I were in the situation where I could no longer take care of myself. But now I do. Now I have an idea of what I might want to look into, just as something to plan for before it becomes a desperate necessity. Dr Gawande's book has at least set some basic groundwork for me to work on.
His case studies are compassionate but pulls no punches. We're introduced to people and their families who have to are determined to hold on to their lives regardless of cost and the pain they'd have to endure to do so, in addition to others who are equally determined not to go through procedures that may prolong their lives if it means they need to give up aspects of their lives that are more important to them.
Discussions of death and how far one should go in treating terminal illnesses are never easy, not only between doctor and patient but between patient and his/her family members. But if there's one thing that has been made blatantly clear to me in reading this book, it's that it is a very important discussion that must be held if one is to ensure that one's own wishes are to be upheld when one reaches the point where one may not be in a position to determine the next course of action.
That might make this sound like some hippie holistic-medicine manifesto. (You know the kind of thing: "Forget all the reductionist Western medicine, man! You've got to, like, treat the spirit with positive energy!"). It's absolutely not. Gawande's approach is very much grounded in medical reality, and he's got some actual science on his side. (E.g., the study that concluded that, counter-intuitively, terminal patients placed in hospice care actually lived longer, on average, than those who aggressively treated their conditions.) This isn't primarily about science and statistics, though; throughout the book, he focuses on real human beings and how they, their doctors, and their family members deal with infirmity and death, in all their awful complexity. This includes stories of his own family members, some of which must have been incredibly difficult to write about, but which I think are invaluable in helping the reader to connect to these issues on a human level.
His conclusions, ultimately, are ones that make a lot of sense to me: Doctors should be better prepared to deal with these concerns and to talk honestly with their patients about them. Everyone should have the difficult discussions about their end-of-life wishes ahead of time, especially those with terminal illnesses. Nursing homes should think of and treat the elderly less like hospital patients and more like people who need help to live lives that still have meaning. And doctors and patients should together consider not simply the question of what actions might help to shrink a tumor or prevent a broken hip, but on how to maximize the overall well-being of the person, given their individual priorities for what matters to them in the time they have left.
I was honestly a little reluctant to start this book, fearing it would be entirely too depressing. And I suppose it is, a bit. Aging and death are sad and scary subjects, and some of the stories Gawande tells are heartbreaking. (The descriptions of miserable, hopeless people in nursing homes particularly got to me. Being a woman with no children and meager savings, I fully expect that will be me someday, and the thought is terrifying.) But the book itself is hopeful, with genuinely useful suggestions for how we can make these things easier, both individually and as a society. And the writing is utterly compelling. It seems very odd to say "I couldn't put it down" about a book of this kind, but it's true. I couldn't. I ended up reading it all in less than a day.
Rating: A book this good about a subject this important surely cannot receive anything less than a 5/5.
There's a lot of information in this book. As the child of aging parents, what I took out of it is different from what my father did, or that any other person would, depending on where they are in their life's journey. My main take-aways were learning which questions are important to ask, primarily in determining what my parents want at each point along the way. It's not really important what I see as the best thing to do; and when parents age and aren't perhaps as sharp as they once were, it's easy to take over decision making. Doctors are also prone to pushing medical procedures that may prolong life, but at the cost of the person being able to enjoy the time they have left. Gawande looks at whether people prefer to live longer, or whether they prefer to live for a shorter time, when that extra time is spent in a bed, unable to do the things that once brought their lives meaning. We all have a story, he says, and we need to be able to shape that story to its end. He looks at how our desire for safety has made the elderly less independent, and our desire for our parents to receive the best possible care takes away our parents' privacy.
Gawande takes us through the experiences of various people, and how the decisions they made, or that were made for them, made them happier or reduced their independence. He also looked at some new ideas in how to care for the aging and what has had an impact in making people content with where they are.
This is an important book, especially for anyone with aging parents, or who are aging themselves. We may not need the lessons learned in Being Mortal yet, but the more we discuss and plan for the future now, the easier it will be.
In a nursing home, the official aim of the institution is caring, but the idea of caring that {has evolved doesn’t} bear any meaningful resemblance to what {some} would call living.
I’ve been looking forward to this book since I read what became a chapter of it -- Gawande’s New Yorker essay, “Letting Go” (Aug 2, 2010). Of several similar books I’ve now read as my parents aged into their nineties and died, and as I age well into middle age, this is absolutely the best.
Best because it addresses the big picture. First, what makes life worth living? Almost always, the answer includes a desire for even fragments of independence and quality of life, not necessarily length of life. Second, in the face of a growing mortal blow to that life, which care/treatment options point toward what you desire vs. away from it? Often, that answer then obviates the need for ponderous research into life-lengthening caregiving and therapies.
Gawande begins with independent old-age and then explores decline; caregiving (family; and the creation of senior living spaces, assisted living, and nursing homes); life-improving vs. life-lengthening healthcare interventions; and hospice. Throughout, he’s philosophical, informative and poignant, in a combination that inspires inexplicable optimism. Highly recommended.
Anyway, Being Mortal is a must read. It's a look at aging, a look at medical care for terminal patients and a discussion about when enough
In all honesty, I can say this book may have changed my life since I'm reevaluating my career choices in part because of aspects of health care that Gawande discusses here.
Then pushes into modern concepts of dying and of the importance of "authoring our own story" up to the end of our lives and the importance of talking about living well, especially near the end of life, rather than about "dying well." This section of the book is emotionally charged and will likely provoke a range of reactions. He discusses some of the medical literature demonstrating that treatments and interventions directed at "curing" one specific disease in an already debilitated patient may shorten, rather than prolonging, life in addition to the more widely recognized side effects and adverse effects on quality of life associated with "aggressive" chemotherapies and surgeries. These concepts do not extrapolate well to all situations and everyone's death, even from similar disease, is unique, so that the challenge of talking about and planning a good life in the face of impending but still uncertain death is enormous. Every physician and indeed every loved one of a dying patient knows this, but as Gawande points out, we only die once, which doesn't allow for practice.
Our training in medical school currently presents two models of the patient-physician relationship, one older paternalistic model ("The physician knows best") and one newer retail model ("The consumer is always right"). A third way, suggested in the later chapters, of an interpretive patient-physician relationship may more realistically meet the challenge. Several stories of patients and his own family members (grandparents and, poignantly, his father) illustrate and humanize the narrative.
More depth in the patient-physician relationship would have been appreciated. Also the argument for death on its own time because of the importance of the "dying time," the phase of life where many of us consolidate some of our lives' lessons into wisdom for future generations, either as legacy planning or more intimate one-on-one "farewells", also seems to deserve more attention.
Throughout, what I thought of most was how perfectly this book responds to the first aphorism of Hippocrates: "Life is short, and Art long; the crisis fleeting; experience perilous, and decision difficult."
When I learned about this book, I was really excited, because I'm a fan of his and I'm also very
I'm glad I did. He's a treasure. I'm glad he's writing, because he's raising awareness of all kinds of important issues among lawmakers and individuals like myself. His writing style is incredibly accessible. This is a must read.
It's wise, moving, insightful, heartbreaking, heartwarming, heartgrowing. It's about dying. It's
"{O}ur decision-making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality. If end-of-life discussions were an experimental drug, the FDA would approve it."
"{Y}our remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. Why would a football fan let a few flubbed minutes at the end of a game ruin three hours of bliss? Because a football game is a story. And in stories, endings matter." Including the stories of our lives.
Bring some kleenex - for the happy stories, for the stories when things are done right. What questions should we ask, what goes into solid decision-making? Gawande does his homework, going to facilities, and talking with patients and doctors and specialists, including palliative care practitioners and geriatricians. He cites the results of critical studies in plain English. He looks at failures, including some of his own, and what goes into creating a success. He painfully but successfully applies what he has learned to his patients and to the distressed health of his own father.
We've been wrong about what our job is in medicine." Read this to find out why. What an extraordinary book. Un-effing-believable. Five stars.
The book begins with concerns about loss of independence in the elderly and ends with loss of life. People live longer now than they did two centuries ago and have easier access to aggressive medical care which may further prolong life. New ways are being developed to provide safe housing for the elderly, but it's just as important to address their psychological needs. Impending death, likewise, should not merely be concerned with prolonging life, but it should also address quality of life.
Atul Gawande talked about his father's illness and death while revealing which actions worked in his family and which didn't. He shared his experiences in order for readers to think personally ahead of time about what we expect for ourselves and those we love as we age. To sincerely listen to the desires of our elderly and to put those desires into action is the most important message of the book.
It's likely, of course, that all of our
He offers hospice care as the alternative to surgery, chemo, radiation, etc, that offer no relief from pain and no hope of recovery. Based on studies he cites, people actually live longer with good hospice care, if they use it as a means of creating a better death, so to speak.
There is also a well written section on assisted living, and Dr. Gawande shares the saga of his own doctor father's death, during which, as son and doctor, he struggles with the same issues as he does with his own patients.
Very highly recommended. Will make you think and think hard.
I really wanted to read Being Mortal after reading an excerpt several months ago in The New Yorker. The chapter is called "Letting Go," and the piece followed a young mother diagnosed with cancer making end-of-life care decisions.
Gawande starts the book with some history of medicine and elder care options (he's part sociologist, part gerontologist, part surgeon, part son throughout the book). As a book about things that people find difficult to talk about, this book is invaluable. As a manifesto about reforming nursing homes and assisted living centers, it's very effective.
As tough as the subject of this book is, it was a very good: the writing is not dry. And because he uses stories about his own family members as well as some stories of his patients, Gawande is constantly providing context to his points about how to lead a meaningful life while you are dying.
Highly recommended.
The other major point of the book is that in our modern era the care of the elderly has become entirely too medicalized, and this is not a good thing. Rather, the goal should not be strictly to ensure survival, but to "enable well-being. And well-being is about the reasons one wishes to be alive." Every person will have a different definition of "well-being," and we need to start having discussions (and deciding for ourselves) what quality of life or well-being will make our own life worth living.
Highly recommended.
4 stars
One of the strengths of Gawande’s analysis is that he shows why traditional models of caring for the dying have gained such traction, and why we make choices that are agains t the best interests of our loved ones. He also explores ways to change the system so that it leads people to make choices that are more aligned with their core values. Stories of individual people who face their own mortality infuse the book with depth and heart. As our population ages, these issues will come more and more to the fore.
My neighbour’s end of life journey is in all likelihood one that is rarely seen these days. It took him a mere 6 weeks to go from diagnosis to coffin. I visited him during that time - he did not go to hospital to die. I bought him books from the library. I helped him with his crossword puzzles. I sat and talked with him although he spoke less and less as the cancer progressed and choked him to death (that’s how it seemed me at the time). There was no surgery, the x-rays that produced the diagnosis ( a public mass chest x-ray screening in a mobile x-ray unit outside the local pub) convinced the doctor and the family that cutting him up as it was then known would do nothing to stop his death coming for him. He had pain control and he had his family around him and he had the reassurance that it was not going to take very long. He had a good end of life and that is a rare thing these days.
Gawande has looked at modern ends of life and suggests several quite simple changes we could make that would make many more ends of life good - simple and, once pointed out, obvious. I’ll not reveal them here in an attempt to tempt you to read the whole thing. I had thought that this book would be all about old age and nursing homes and the pointless prolonging of life and while Gawande covers all of these things he covers what we would now think of as premature ends of life as well and he does it without unnecessary statistics and with humane anecdotes of real ends of life. He is not coruscating about the failures that we have introduced into a totally natural process because he understands how and why these things have happened but he has the sense to stand back and observe closely. What I found most enlightening was to get a medical man’s perspective on the whole journey: it seems that even hardened medicos are uncomfortable discussing actual death, preferring to engender hope rather than reality. In fact I think that doctors should be made to read this book. Mind you, I think everybody should read it. If you think you might die one day, and even if you don’t, YOU should read this book.