Wednesday, March 25, 2015

Being Mortal, by Atul Gawande

Subtitled Medicine and What Matters in the End, Being Mortal is a clear-eyed examination, illustrated with cases from surgeon-author Gawande's practice and family, of the disservices our culture--particularly our medical culture--does to the elderly and the terminally ill. The first part of the book deals with aging and how we can best care for people who have become unable to care for themselves. Gawande provides an overview of the history of elder care and discusses innovations of the past several decades, including the original concept of assisted living and the move to create small communities of frail people living on their own schedule rather than being regimented to meet the needs of a large elder-care facility. Gawande stresses that the goals of family and physicians--to keep the frail elders safe--are not necessarily aligned with the desires of the people themselves, which may be to maintain some control over their own lives or to feel that their lives still matter. This distinction is important, but (speaking as someone with a parent in assisted living) not always easy to be responsive to.

A similar distinction is at the heart of the second section of the book, in which Gawande examines how doctors react to terminal illness. Trained to fight death to the bitter end, doctors may cause unnecessary suffering and undoubtedly drive up medical costs by putting patients in intensive care rather than letting them live out their last days at home or by recommending additional rounds of chemotherapy that are almost certain to be ineffectual. Gawande suggests that doctors need to move beyond the two models of physician behavior in which they were trained--the doctor as all-knowing "godlike" expert who tells patients what to do or the doctor as informer who gives the patient the options available and then instructs the patient to decide what course to follow. Instead, he recommends that doctors ask patients what their goals are and then, with the patients, determine a course of action that will help them meet those goals. Although he started as something of a skeptic, after spending time with hospice staff, Gawande also advocates for hospice care as an option that can alleviate suffering and help patients live and die as they wish.

At the end of the book, Gawande briefly discusses euthanasia.

Being Mortal presents a variety of ideas that should be of particular interest to physicians, those advancing in age (such as myself), and those with elderly parents or terminally ill relatives. I noted that the reviewer in the New York Times expressed skepticism about some of Gawande's claims and citations, but I didn't read the book as a scientific study but as one doctor's journey to a new way of thinking about end-of-life decisions. As such, I thought it was effective and well-written with case studies that touched the heart.

I should note that I listened to the audio version of the book, ably read by Robert Petkoff. Since I have had trouble getting through a couple of print books on similar topics, I am developing a hypothesis that listening to this emotionally challenging material may be easier than actually reading it.

Favorite passage
In the end, people don't view their life as merely the average of all its moments--which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people's minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life may be empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.

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