Being Mortal: Medicine and What Matters in the End

by Atul Gawande

“The necessity of nature’s final victory was expected and accepted in generations before our own. Doctors were far more willing to recognize the signs of defeat and far less arrogant about denying them.”

This book poses a really good question about how to go about end of life care. At what point do we accept a patient is dying and follow their wishes? When would it be inappropriate to continue attempts at saving a patient’s life? Who’s job is it to decide?

coming from India he felt it was the family’s responsibility to take the aged in, give them company, and look after them.

Cultural differences: this is a difference evident in western cultures versus eastern cultures. After reading this book, I wonder if it’s better to keep family at home when their at the end of their life versus putting them in a nursing home. If there are more likely to live a happy life (although shorter) and families are less likely to suffer from depression after the family member dies.

But one thing he could never get used to was how we treat our old and frail—leaving them to a life alone or isolating them in a series of anonymous facilities, their last conscious moments spent with nurses and doctors who barely knew their names.

He emphasized education, hard work, frugality, earning your own way, staying true to your word, and holding others strictly accountable for doing the same.

Had he lived in the West, this would have seemed absurd. It isn’t safe, his doctor would say. If he persisted, then fell, and went to an emergency room with a broken hip, the hospital would not let him return home.

Medicalization: is it more important that patients are safe or that they are happy?

The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.

This is an interesting perspective. I’ve always felt that society glorifies youthfulness.

The problems were only going to increase. Her independence would not be sustainable for long now. But he had no answers or direction or guidance. He could not even describe what to expect would happen.

What is the role of a doctor in helping unsolvable problems?

Yet traveling along these altered paths, we regard living in the downhill stretches with a kind of embarrassment. We need help, often for long periods of time, and regard that as a weakness rather than as the new normal and expected state of affairs.

Those of us in medicine don’t help, for we often regard the patient on the downhill as uninteresting unless he or she has a discrete problem we can fix.

I wonder if this is the case when it comes to chronic illnesses as well.

Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010.

Give us a disease, and we can do something about it. But give us an elderly woman with high blood pressure, arthritic knees, and various other ailments besides—an elderly woman at risk of losing the life she enjoys—and we hardly know what to do and often only make matters worse.

Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.

Many of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.

More than half of the elderly living in long-term-care facilities run through their entire savings and have to go on government assistance—welfare—in order to afford it.

how we seek to spend our time may depend on how much time we perceive ourselves to have.

Nothing that takes off becomes quite what the creator wants it to be.

In fact, he argued, human beings need loyalty. It does not necessarily produce happiness, and can even be painful, but we all require devotion to something more than ourselves for our lives to be endurable. Without it, we have only our desires to guide us, and they are fleeting, capricious, and insatiable.

The question therefore is not how we can afford this system’s expense. It is how we can build a health care system that will actually help people achieve what’s most important to them at the end of their lives.

You worry far more about being overly pessimistic than you do about being overly optimistic.

In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish.

paternalistic relationship—we are medical authorities aiming to ensure that patients receive what we believe best for them.

“informative.” It’s the opposite of the paternalistic relationship. We tell you the facts and figures. The rest is up to you.

“interpretive.” Here the doctor’s role is to help patients determine what they want.

Benzel saw himself as neither the commander nor a mere technician in this battle but instead as a kind of counselor and contractor on my father’s behalf. It was exactly what my father needed.

Is it possible as a doctor to change the relationship structure based on patient needs?

Dr. Informative was clearly not sufficient to help Sara Monopoli or the many other seriously ill patients I’d had.

Is the shared decision model the "perfect" approach for everyone? Can there be one approach for everyone?

One has to decide whether one’s fears or one’s hopes are what should matter most.

that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer;

When it got worse, one physician even recommended seeing a psychiatrist and gave her a book on “how to let go of your pain.” But imaging finally revealed that she had a five-inch sarcoma, a rare soft-tissue cancer, eating into her pelvis and causing a large blood clot in her leg.

How do we avoid “medical gaslighting”?

But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.

This quote is really interesting. I think we all know that science has its limits. So is it acknowledging that medicine has finite power or that we have a finite ability to “fix things”?