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addabook - Being Mortal
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Being Mortal
Medicine and What Matters in the End
Atul Gawande
read on September 18, 2018

Being Mortal is probably one of the most important books I'll ever read. It's not so much a narrative (though, there are a series of personal stories throughout that are very compelling), but moreso it's a wakeup call that hard conversations are unbelievably necessary. The book is broadly about the American experience of growing old and dying. I actually read it for the first time a few years ago after seeing a review in a newspaper article. I thought it was powerful then, but somehow it didn't make it into these reviews. I hope I'll read it several more times in my life. [As a brief aside, I'm incredibly happy and proud that he got the job as CEO of the Amzn/Berkshire/JPM healthcare initiative, and I'm very excited to see what comes of his work there].

The driving force of the book is the end of the subtitle: 'what matters in the end'. Gawande describes the process of aging, and particularly the evolution of how American's have treated the elderly. The first half of the book is about nursing homes, why they're so often feared and disliked, and the kinds of things that make them more tolerable, and borderline even enjoyable. (No surprise; autonomy, purpose, being around other living things [animals, plants]). Gawande espouses Assisted Living over nursing homes, though concedes that the term has been co-opted and is no longer necessarily safe. This was all very interesting.

The second half of the book is about the process of dying itself. About how in America in particular, we have a healthcare system that almost doesn't allow people to die with dignity. Doctors aren't trained to let people die, they only know how to offer potential solutions.

We've created a multi-trillion dollar edifice for dispensing the medical equivalent of a littery tickets. And have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan. But, hope is our plan.

Doctors will only explain what possible treatments exist in order to potentially help; and not necessarily meaningfully help. The purpose of doctors is to allow you to live the life you want to live. But to doctors, their purpose is to cure disease/ailments. These do not always align, particularly when one is no longer possible. Doctors seem to err on the side of aggressively trying to stop a sickness, even if it means increasing the likelihood of the patient spending their last days suffering in a hospital - something that overwhelmingly, most people would not prefer, even if it meant living a shorter life. People have awful deaths in the US, simply because we're pushed - by doctors, by family, by people with good intentions but without understanding and true empathy - to fight to the bitter end. Death used to happen at home. Death used to be peaceful.

A study led by the sociologist Nicholas Christakis asked the doctors of almost 500 terminally ill patients to estimate how long they thought their patient would survive, and then, followed the patients. 63% of doctors overestimated their patients' survival time. Just 17% underestimated it. The average estimate was 530% too high. And the better the doctors knew their patients, the more likely they were to err.

Gawande suggests the following questions to discuss with someone - preferably before they're terminally ill - but better then than never:

  • What are you biggest fears and concerns?
  • What goals are most important to you?
  • What trade-offs are you willing to make, and which aren't you? 

When you've had this conversation properly, you stand a much better chance to make decisions for yourself and your family that you actually want, that you won't regret.

As for last words, they hardly seem to exist anymore. Technology can sustain our organs until we are well past the point of awareness and coherence. Besides, how do you attend to the thoughts and concerns of the dying when medicine has made it almost impossible to be sure who the dying even are?

Author Bio:

Atul Gawande, MD, MPH, is a surgeon, writer, and public health leader. He is CEO of the non-profit-seeking health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase to deliver better outcomes, satisfaction, and cost efficiency in care. He practices general and endocrine surgery at Brigham and Women’s Hospital. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. He is the founding executive director and chairman of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit organization making surgery safer globally. Atul has been a staff writer for The New Yorker magazine since 1998 and has written four New York Times bestsellers: Complications, Better, The Checklist Manifesto, and Being Mortal: Medicine and What Matters in the End. He is the winner of two National Magazine Awards, AcademyHealth’s Impact Award for highest research impact on healthcare, a MacArthur Fellowship, and the Lewis Thomas Award for writing about science.