Being Mortal: Medicine and What Matters in the End

by Atul Gawande

So this is the way it unfolds. In the absence of what people like my grandfather could count on—a vast extended family constantly on hand to let him make his own choices—our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.

Thomas believed that a good life was one of maximum independence.

we all require devotion to something more than ourselves for our lives to be endurable.

We become less interested in the rewards of achieving and accumulating, and more interested in the rewards of simply being.

NewBridge on the Charles.

Research has found that in units with fewer than twenty people there tends to be less anxiety and depression, more socializing and friendship, an increased sense of safety, and more interaction with staff—even in cases when residents have developed dementia.

Here, however, she walked. Clearly there were risks. Nonetheless, the staff there understood how important mobility was—not merely for her health (in a wheelchair, her physical strength would have rapidly deteriorated) but even more for her well-being.

It was not unusual for children and residents to develop close individual relationships.

She still wants to make it possible for everyone to live out their days wherever they can call home.

Beacon Hill Villages, a kind of community cooperative in several neighborhoods of Boston dedicated to organizing affordable services—everything from plumbing repair to laundry—in order to help the elderly stay in their homes.

The amount of freedom you have in your life is not the measure of the worth of your life. Just as safety is an empty and even self-defeating goal to live for, so ultimately is autonomy.

Whatever the limits and travails we face, we want to retain the autonomy—the freedom—to be the authors of our lives.

The residences are designed to be warm and homey—with ordinary furniture, a living room with a hearth, family-style meals around one big table, a front door with a doorbell.

Sounds like a commune from the Sixties.

They ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world—to make choices and sustain connections to others according to their own priorities.

“A nurse has five seconds to make a patient like you and trust you. It’s in the whole way you present yourself.

An opportunity to prepare for the inevitable was forgone. And it all happened because of an assuredly normal circumstance: a patient and family unready to confront the reality of her disease.

Most of them enrolled in hospice. They suffered less, were physically more capable, and were better able, for a longer period, to interact with others.

The lesson seems almost Zen: you live longer only when you stop trying to live longer.

If you are talking more than half of the time, Block says, you’re talking too much.

you shouldn’t say, “I’m sorry things turned out this way,” for example. It can sound like you’re distancing yourself. You should say, “I wish things were different.” You don’t ask, “What do you want when you are dying?” You ask, “If time becomes short, what is most important to you?”

Death is the enemy. But the enemy has superior forces. Eventually, it wins.

He had that midwesterner’s habit of waiting a beat after people have spoken before speaking himself, in order to see if they are really done.

Interpretive doctors ask, “What is most important to you? What are your worries?” Then, when they know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities.

She was experiencing what I have come to think of as the ODTAA syndrome: the syndrome of One Damn Thing After Another.

This is what it means to have autonomy—you may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.

THE CHOICES DON’T stop, however. Life is choices, and they are relentless. No sooner have you made one choice than another is upon you.

The discussion became difficult for me or my parents to follow, despite all three of us being doctors.

We witnessed for ourselves the consequences of living for the best possible day today instead of sacrificing time now for time later.

the chance to shape one’s story is essential to sustaining meaning in life;

I explained how hospice’s aim, at least in theory, was to give people their best possible day, however they might define it under the circumstances. It seemed like it had been a while since she’d had a good day, I said.

Each day, he found moments worth living for.

Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?

But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life. When we forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.

When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that there are times when the cost of pushing exceeds its value.

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Ariadne Labs, the joint innovation center that I lead,

Tina Bennett has been my tireless agent, my unstinting protector, and, going all the way back to college, my dear friend. Although everything about publishing books is changing, she has always found a way for me to grow an audience and still write what I want to write. She is without peer.

Sara’s dedication is the reason this book says what I wanted it to say. And that is why it is dedicated to her.