Being Mortal

Powerful read that changes perspective on aging and medicine. Pros: Insightful, meaningful Cons: Emotionally heavy

I had not really thought through the issue of quality of living versus safety and medical interventions. BEING MORTAL has been so helpful to start the wheels turning in productive thinking ahead of my own and my husband's golden years and likely decline of our physical bodies. Much to think about after reading this! For anyone of any age who wants to have their views on aging well-thought out and well-formed before needing to make important decisions in this area. Easy to read. Though written by a physician-surgeon, it is understandable by anyone, with warmth and honesty in the writing. Many real-life examples, helpful and relevant. I worked as a nurse's aid at a state nursing home when I was in high school and still have vivid pictures in my mind of dear older folks spending their days doing nothing but sitting in wheelchairs in the hallways, of bare rooms, of institutional clothing and regulated mealtimes etc. Reading this, particularly some of the stories, and statistics on rate of decline in institutions as compared to at home care gives much to think about. Aging in place may be a new term, but the concept is the way things were done before the advent of nursing homes. (of course some cultures just left their sick elderly in the woods to die, but that's another story). What is new in our day is all the help available to make staying in one's home, or with family easier, practical (as far as possible), and so on. One has to ask, "is my family preparing to handle aging in a way that preserves quality of living as much as possible? This book may inspire some going into medicine to consider geriatric medicine, a field that is desparate for more doctors. Well, this read is a breath of fresh air in pointing out how quality of living just might be more important than safety or another medical prodecure. I will read it again as the years accumulate and I want to make good and wish choices for myself and my husband. I've already shared concepts and stories from it with my daughter. It was a great impetus to get us talking about our views for elder care and how we want to approach that if and when help is needed.

Gawande's style is like cool jazz -- confidential and unhysterical in tone, far-ranging and penetrating in its insights --with big takeaways. 1. We have made a hash of end-of-life medical treatment, and cause unnecessary suffering by over-focusing on extending time rather than on human values, such as meaning and comfort, that often matter more to dying people. 2. We tend to want freedom for ourselves and safety for those we love -- hence nursing homes and assisted living setups that rob their residents (inmates really) of autonomy, joy & purpose, even when well-run. 3. When a patient says, "Save my life, doc!" he/she usually means "restore me to my previous life!" (save my life, doc, not my mere body.) That is often impossible, and doctors (including, Gawande admits, himself) often choke on saying so. 4. Among the crucial 4 questions to ask a chronically/critically ill person: "what would a good day look like to you?" Gawande is an MD with an eagle's overview of the medical landscape and a confidential, intimate writing style. His comparison of the death of his grandfather (in India, surrounded by supportive relatives, at 110, with no Hail Mary medical interventions) and that of his wife's grandmother (alone in assisted living in the US) is poignant. He's brilliant at painting the big picture with a light, seemingly effortless touch. In researching my own book, "Knocking on Heaven's Door" (which explores end-of-life medicine from the vantage point of a daughter-caregiver,) I absorbed many lessons from Gawande's award-winning work in the New Yorker, which forms the backbone of this book. Three cheers to Gawande for helping break through the confusion and terror surrounding medicalized death, and for highlighting the docs and nurses (especially in palliative care and hospice) working tirelessly towards a better way of death. PS Gawande would have a close-to 5 star rating, except for a one-star review from someone who doesn't like "Obamacare." I bet as the reviews roll in, this will balance out. This book will help reform medicine from the inside out and will be useful to all practicing physicians and health policy people. It doesn't, however, "follow the money," and that is a crucial shaper of poor end of life medicine. It won't all be solved with better communication. Below, some companion how-to books I found useful as a family caregiver. Knocking on Heaven's Door: The Path to a Better Way of Death Memoir and map, plus investigative reporting on the economic drivers of medical overdoing near the end of life. My Mother, Your Mother: Embracing "Slow Medicine," the Compassionate Approach to Caring for Your Aging Loved Ones THE best manual for family caregivers of the aged, by the geriatrician who pioneered "Slow Medicine" in the US. Covers the last chapter of life -- from first decline to what McCullough calls "Prolonged and Attenuated Dying." Hard Choices for Loving People: CPR, Artificial Feeding, Comfort Care, and the Patient with a Life-Threatening Illness, 5th Ed. A hospice chaplain discusses when to stop pain-inducing medical measures from a practical and low-key spiritual perspective. Short and gentle, narrowly focused on end of life. Over 4 million copies in print. Can't We Talk about Something More Pleasant?: A Memoir Hilarious graphic memoir of parental caregiving, by Roz Chast. Everything you felt but dared not say!

I've read Dr. Gawande's other writings as well, and they are deeply honest, thoughtful, non-arrogant and constructive. This book is no exception. Sadly, it remains true that most "nursing homes" and nursing home programs are hospital-like and organized more for the staff than for the patients (and yes, they ARE patients). While it sounds grand for people with significant disabilities to take risks for themselves, we should not forget that personal injury lawyers are close by and all too willing to sue the facility for an injury that the patients themselves caused. Lawsuits against multi-care facilities interrupt the process of taking care of patients. We live in a litigious society. Surely Dr. Gawande knows this. We need to remember that the primary care-givers of nursing home and extended care facilities are not well paid and many are transient. This is one factor that is ignored by Dr. Gawande in his analysis. Non-professional care givers need to be carefully managed and observed. Having a regimented program for patient care allows senior staff members to more closely observe them to make sure they don't steal or abuse patients under their care. States (like California) have enormous social care costs and increasing the pay of care-givers is not in the sights of the legislatures. Care in this field is like everything else: You get what you pay for. When caregivers last only a week due to the low pay and "difficult" working conditions, another substitute must be trained to take over in their stead. I wish Dr. Gawande had some analysis of this issue and ideas about it. On another subject of his surgeon-father practicing well into his illness from a tumor pressing against his brain-stem and upper spine, his father continued to practice urologic surgery very much longer than I as a physician would have liked to see. The (Sr.) Dr. Gawande was already experiencing numbness in his hands and no doubt his proprioception was diminished. If I were under-going prostate-nerve sparing surgery from him, I would wonder if he could adequately "tease-out" the motor nerves in the cancer ridden prostate. I think it is nice and elegant for people to work well into their disabilities and even serious illness. But when it comes to surgery, I think it would have been better if the Sr. Dr. Gawande had retired from surgery when he realized he was damaged and instead became a lecturer at a local medical school. I'm frankly surprised that this was allowed; and I think it was wrong. His patients had a right to know. All of this is not necessarily off-topic. Care (even the wonderful models Dr. Gawande proposes) must be paid for. There is no such thing as "free-care." Promises from President Obama and TV commercials for Obama-care sometimes suggest that medical care is an entitlement that is free. Well, it's not. It never will be. Dr. Gawande tends to "brush aside" the issue of patient-directed suicide as a kind of cop-out to get away from proper hospice care. Hospices don't always have the answers. In particular in the case of bony metastases and pressure of tumors directly against nerve tissue. Spinal metastases in particular are not well controlled by narcotics. If this is all the hospice has to offer, it is insufficient. Sometimes anesthesiologists can be called upon to implant direct pain control in specific sites if that is indicated. But that is not always possible. Dr. Gawande's own father complained of pain, and even in the face of better medication management, the son admits that pain control was inadequate for his father. These are cases where patient intervention by "premature" death is indicated and appropriate. Spinal metastases are just one example. Patients in every state should be offered the potential of medications to end their lives for inoperable cancers and conditions like advanced emphysema. The dose of narcotics necessary to relieve "air-hunger" is often close to a fatal dose. Some oncologists feel themselves under pressure from DEA to avoid those concentrations. An investigation from DEA will end their career. This may cause them to be skittish about giving the patient what they actually need. If state laws permitted patient-directed suicide this would not be an issue. There are no easy answers. But it is not always "bad" for an elderly, severely compromised patient to be in an extended care environment that "looks and operates" like a hospital. My father-in-law was in such a place and was very happy. He had nice relationships with care-givers who lovingly took care of him, even if the "place looked like a hospital." I do think it is possible to construct an extended care facility like a dormitory with small, localized living areas. But senior staff may not always be available to monitor each of these discrete locations. Care audits are much more difficult to perform. This is not always optimal, even though Dr. Gawande insists that it is. One of the strong points of his book is "conversations" with your elderly patients, whether they be actual patients or your own father and mother. When confronted with this issue for my father-in-law, we simply explained to him that it was "unfair" for his daughter to have to make decisions for him without some kind of "direction." We did not influence his judgment in any way. We explained what a feeding tube was and told him plainly that if he wanted this...this is what we would do. We did our best to present the options without any bias at all. We actually rehearsed it first to make sure we avoided them. We knew what he wanted because he told us. It was not easy. It's not meant to be. It is possible to discuss these painful issues with your elderly parents. Or you could hire an attorney to do it for you, if you fear that you are not "unbiased" enough. We also gave that option to my father-in-law if he wanted. (We would pay for counsel ourselves). He refused, but we would gladly have done it. I don't mean to be overly-critical of a fine book with many fine and heartfelt ideas. Dr. Gawande is a caring, able physician whom I would glad to have as my own. These are just some of my own ideas; and I hope they are reasonable. (Dr.) Michael M. Rosenblatt

Doctor & public intellectual Atul Gawande’s 2014 book Being Mortal: Medicine and What Matters in the End basically deserves all the praise it receives. Although it is more about modern aging then about death per se, it certainly fit my mood at the moment. My father, a brain cancer patient in his mid-60s, has been given a push along on this path, so it was still helpful to me to think about aging and decline more generally (significant decline prior to death will happen even in most best-case scenarios — and anyways you can’t know in advance if it really won’t). Being Mortal essentially provides a long, thoughtful, multi-faceted, historically-grounded complaint about the medicalization of aging and death, from someone who really knows and cares. Older adults may become less capable of caring for themselves in various ways, but for the most part they still want the things they always wanted: autonomy in their schedules and surroundings, community, privacy, a specific and concrete reason to get up in the morning. It’s a hell of a demand, to ask people to adjust to completely new surroundings and routines when they’ve never been older and/or sicker. Institutions like hospitals and nursing homes are sort of good at providing some things (specific instances of treatment) and terrible at providing others (emotional warmth, exceptions to the rules, etc). The “assisted living” concept has an interesting history (read it in the book!). Unfortunately, by now assisted living has become a watered-down way station between hospital and nursing home, rather than remaining a bastion of alternative values in elder care as originally conceived. Indeed, the logic of institutions is largely inexorable. If providing meaning (or a lifestyle ripe for it) cannot be measured and incentivized, it will not be reliably or scalably produced. Admittedly, Being Mortal raises more questions than it provides answers. Everyone loves a good news story about kindergarteners who visit nursing homes. But are they changing diapers? Is there really any feasible model for caring for a rapidly aging population other than institutions? And how are you supposed to reward institutions for preserving meaning (an inherently individual task) even while they do the things that institutions are meant to do – get a lot of services provided quickly/reliably in a standardized fashion? No individual person can change the system anyways, but it does seem that (even within the system we’ve got) people are making some crap decisions. Ok, so people are valuing the wrong things – namely, safety over autonomy and the “lottery ticket” of survival/recovery over a better death, sooner. You’re someone who wants to value the right things. So what do you do? You have to do your own research and ask doctors hard questions, because they don’t really like facing imminent death either. You have to broaden your imagination about what acceptable living arrangements for an older person might look like.For instance, maybe you have to accept that your loved one might not get medicine exactly on time or the diet just as the doctor prescribed, because he’s going to sleep in his own bed and raid his own fridge instead. But maybe people don’t want to do those things. Then what? That brings us to my main quibble with Being Mortal: Gawande waffles a bit between what people do value and what they should value. It’s so tempting to talk a big game about what “matters.” But if something really matters, why don’t people choose it? Don’t lots of different things matter? And how could it ever be anything less than very difficult to switch from life mode (focus on safety and the long-term) to end-of-life mode? Perhaps Gawande ought to have sought out some different examples of these values in action. It’s not too hard to imagine a terminal patient forgoing last-ditch treatment, even if it’s not what we’d choose ourselves. It’s much more difficult to imagine a role model of, for instance, an adult child allowing her parent to live in what are widely considered to be “unsafe” living conditions specifically for the sake of that parent’s broader well-being. I want to see examples of real “free-range” senescence. I’d like to read the account of someone who got a call from the police, who found mom passed out in the yard, or even whose parent died in an accidental house fire or something. Many worst-case scenarios (of elders living unaided) will not come to pass, but some certainly will. Then what? Does that change people’s minds, one way or the other? Like trendy “free-range parenting,” it’s probably just much easier said than done. Does that mean a value is going unrealized, or that the person doesn’t hold it in the first place? Maybe many patients don’t even know what they value the most. That’s fair, and part of what palliative care can help them to define, as it becomes increasingly relevant. But maybe there’s nothing satisfying to uncover. There’s no rule that everyone must necessarily value different components of life in a stable fashion. Some people will have very consistent desires, but others will vacillate (especially as they experience the stages of progressing towards death). If you draw a patient’s attention to the dangers of her living independently, she shudders. But when you tell a sad story about a nursing home, she cringes. Maybe she fights with her adult children about where she should go. Maybe she can’t afford her first choice. But that’s simple interpersonal conflict and lack of resources, not unique to old age. You can’t live both independently and in a nursing home. Something’s got to give, and that totally sucks. Some values will be pursued better, and some values will be pursued worse, and some kind of balance must be reached. Care institutions put a finger on the scale, but they didn’t create the problem. The personal economy of value pursuit is simply tricky, from the day we’re born until the day we die. Gawande knows that there are costs associated to the “old” way of dying – it tends to create autonomy for elders at the expense of the younger generation, especially women sandwiched between their children and parents. Many children (and parents) aren’t happy with this anymore, for a variety of reasons, so they face new sets of options (i.e. tradeoffs). Having access to medicine is a double-edged sword, and like many historically-novel conditions humans aren’t inherently well-equipped to deal with it. There’s no technocratic solution to that. If “dying as we lived” is some kind of standard for how we should go, then maybe alone and medicalized makes some sense right now after all. I don’t really have any caveats in recommending this one, though. Just read it (and then try to forget Gawande’s description of how aging bodies feel in a surgeon’s hands as quickly as possible). Book #3 for read about death dot com

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!

Really interesting book with a lot of great things to talk about. My husband loved this educational book.

Talking about ones mortality is a definite conversation stopper at many gathering. In our society with the rapid growth of medicines which can cure most diseases or at least elongate the process the reality of dying is pushed well into the future. Death is not an "up" subject, we'll find a way to get around its reality. BEING MORTAL is written with great compassion and wisdom. Dr. Atul Gawande considers both sides of the issue very throughly from the perspective of first the doctor who is the "fixer" of all things medical. All to often our Doctor is locked into the cure, a full on no holds chemical battle with the illness and is not able or will ing to address with the patients the fact that this illness will cause the patients death. It is not going to go away. Many doctors are unable to early on tell the patient that this illness is fatal, you will die once these interventions are exhausted. That conversation is not in their "black bag." The book addresses dying with very personal stories, the experience of patients living with chronic or measurable fatal illnesses. It goes beyond the common, "medical intervention" to look at accepting that this illness is fatal and prolonged suffering with it is optional. When do we, the patient, draw the line in the sand and say, "I'm not going to continue to fight a losing battle, I believe there is another path to follow." The journey I shared with my wife Helen is passionately told throughout the book. There came a time when she had had enough suffering from the standard interventions, "chemo, to surgical procedures." Finally she said that had to stop. Many lines in the book quoted verbatim what we had heard from our doctor, "well there is another new more aggressive chemo we can try now", wait, hold on we've been through three already. BEING MORTAL speaks to the issue of dying from two approaches diverse approaches, facing the reality and living with a chronic illness with a new focus placed on quality of life. Yes, you can die of a chronic illness and still have comfort, control and dignity. At one point in the book Dr. Gaqande puts both sides of the argument in sharp focus when he writes from his honest and realistic viewpoint; "The medical approach applies its own pressure always remaining an all or nothing, in one direction, toward dong more, because the only mistake clinicians seem to fear is doing too little. Most have appreciation that equally terrible mistakes are possible in the other direction - that doing too much could be no less devastating to a person's life." Many readers of this book will understand this point at a very personal level." In the book Dr. Gawande uses statistics in such a way that they become personal and allow you to ponder where we are in 2015 in regard to facing death as a society. From the book one gets the feeling that there is strength in getting involved early with a Hospice program. He states, " those who...entered Hospice far earlier, experienced less suffering and at the end of their lives - and at they lived 25% longer. For some making the decision to die under Hospice care in not an option they will exercise. However, the experiences of many people have had over the past twenty years are beginning to make the case. They speak to the merits of pain management, end of life quality of life. Dr. Gawawda has made it possible for my family to discuss the dying process in real time. We are spending time while we are all healthy pondering the issues together knowing that they surely one day will be as we say, "up close and personal." The book is a road map of sorts into those in their precious last months, weeks or days in the life. For a family about to see a loved one pass on and become an ancestor. BEING MORTAL allows the patient, family and fiends the opportunity to have a final bonding. I know my family and Helen's friends celebrated her life the entire seven months she was dying of cancer. Through it all we had many happy moments. BEING MORTAL mirrored out experience. An excellent book and one I would recommend be read by all medical students, nurses and us the family members who will share the journey with them. Tom Wicks

As a Palliative Care physician of nearly 30 years experience, I have not read a better reasoned or more convincing argument for good palliative care integrated into all aspects of medicine. Sadly, I must agree with Dr Gawande that the continued need for my discipline to exist is a measure of failure, and that true success would see all health care systems capable of doing what palliative care now does as a specialty. This book, written from within medicine, and by a specialist in a discipline often seen as opposing, or at least failing to understand palliative care, is a far more powerful means to that end than any number of earnest lectures from the likes of me. It is so because it is beautifully written, deeply considered, erudite and above all deeply personal. EVERY medical student should read it, and be required to have as much skill and comfort in having difficult but crucial conversations as they do in naming muscles and writing prescriptions.

Such a brilliant book written with such compassion and deep understanding.

Es un libro que está escrito desde un punto de vista muy humano, a la vez que realista, estos dos factores, unidos a una prosa sencilla y clara hacen del libro un antídoto contra el miedo a la muerte, al menos es el sentimiento que produjo en mí que ya tengo 85 años.

Wer sich - aus welchen Gründen auch immer - konkret mit Gebrechlichkeit, Alter, schwerer Krankheit oder Sterblichkeit auseinandersetzen muss, ist sehr gut beraten dieses Buch zu lesen: Der Autor ist kompetent, erfahren, reflektiert und schreibt einleuchtend, eindringlich und einfühlsam sowohl über die Mängel und die Ignoranz im professionellen Umgang mit dem Nahen des Todes als auch - an eigenem familiären Beispiel - über unsere unausgebildeten Emotionen und unsere Hilflosigkeit als Betroffene. Kurz: "Being Mortal" ist auf höchstem Niveau emphatisch, bewegend und informativ zugleich.

This book addresses the inescapable fact called death, how we can face this with dignity, how medical profession can help us in this regard.The author is a surgeon at Brigham and Women’s Hospital in Boston. He is also a successful writer on popular medicine. The book opens with an interesting statistic. In USA, till 1945, most deaths occurred at home. By the 1980s just 17% did. The rest died in hospitals. What is the reason behind this rather expensive ending? The answer ironically is the progress made in medical care. The author gives a scary description of ageing process. Teeth decay is most common. Jaw muscles lose about 40% of their mass and bones of the mandible lose about 20%. Ability to chew therefore declines. While our bones and teeth soften, rest of the body hardens. Blood vessels, joints, muscle and valves of the heart pick up substantial amounts of calcium and turn stiff. Since heart has to exert more to pump blood to these stiffened arteries, we all develop hyper tension. Lung capacity decreases. Even our brain shrinks and actually rattles inside making us vulnerable to cerebral bleeding even with minor head injuries. Eventually death becomes a question of when? Not If. Doctors are trained to keep patients alive as long as possible. They are never taught how to prepare people to die. They therefore subject you to all kinds of therapies and surgeries and prolong life. Should medical profession rethink its approach? Yes! Medical profession at least in developed countries have realized that longevity should be replaced with making life worth living even if it means shortening it. The author now gives various developments taking place and their shortcomings. Geriatrics specializes in Medicare for aged. Unfortunately this is not a glamorous branch like plastic surgery. Consequently doctors and institutions specializing in geriatrics are few in number. What can be a better option than a nursing home for the aged and debilitated? Comfortable bed, nursing care, timely medications, doctor on call and above all not being a burden on the children. On the face of it a nursing home appears ideal and several have come up to suit all budgets. The reality however is different. Old people hate nursing homes. The author explains why? Nursing home is two words. Not one. Besides nursing, it has to be home as well. Prisons, orphanages, mental hospitals and military barracks have striking similarities with nursing homes. It is a regimented life denying adults the much needed autonomy and self respect. Assisted living is a radical improvement over nursing homes. Inmates enjoy better autonomy. The group living concept helps in overcoming monotony. Management allows inmates to take certain risks. The underlying philosophy is happiness of the inmates rather than keeping them alive at any cost. Hospice is an institution that takes care of chronically or terminally ill. There are also hospices at home facilities. In USA it is legal to get consent of the inmate to these questions. Do you want to be rusticated if your heart stops? Do you want aggressive treatments such as intubation and mechanical ventilation? Do you want antibiotics? Do you want tube or intravenous feeding if you can’t eat on your own? The hospice also assists in framing a will and record last wishes of the patient. Hospice also provides palliative care to reduce pain and suffering by administering sedatives, pain killers, psychiatric drugs etc. There are approved procedures and WHO guidelines on palliative care. A modern trend that is gaining support is called physician assisted suicide (PAS). This should not be confused with euthanasia or mercy killing. In PAS the decision to die rests with the patient. The physician merely prescribes a lethal dose of barbiturates and the patient is free to take it whenever he desires. Assisted suicide is legal in the states of Oregon, Vermont and Washington in USA. The book ends on a philosophical note. Dr Gawande visits Varanasi to immerse ashes of his father in Holy Ganges. There is a saying in Hindi. “To attain Moksha, one has to die!” let us therefore accept that we are mortals and be happy about that fact. Being Mortal is good book. I strongly urge you to read it.