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Being Mortal Illness, Medicine and What Matters in the End Paperback – 2015
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"Rebound" by Kwame Alexander
Don't miss best-selling author Kwame Alexander's "Rebound," a new companion novel to his Newbery Award-winner, "The Crossover,"" illustrated with striking graphic novel panels. Pre-order today
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An Amazon Best Book of the Month, October 2014: True or false: Modern medicine is a miracle that has transformed all of our lives.
If you said “true,” you’d be right, of course, but that’s a statement that demands an asterisk, a “but.” “We’ve been wrong about what our job is in medicine,” writes Atul Gawande, a surgeon (at Brigham and Women’s Hospital in Boston) and a writer (at the New Yorker). “We think. . .[it] is to ensure health and survival. But really. . .it is to enable well-being. And well-being is about the reasons one wishes to be alive.” Through interviews with doctors, stories from and about health care providers (such as the woman who pioneered the notion of “assisted living” for the elderly)—and eventually, by way of the story of his own father’s dying, Gawande examines the cracks in the system of health care to the aged (i.e. 97 percent of medical students take no course in geriatrics) and to the seriously ill who might have different needs and expectations than the ones family members predict. (One striking example: the terminally ill former professor who told his daughter that “quality of life” for him meant the ongoing ability to enjoy chocolate ice cream and watch football on TV. If medical treatments might remove those pleasures, well, then, he wasn’t sure he would submit to such treatments.) Doctors don’t listen, Gawande suggests—or, more accurately, they don’t know what to listen for. (Gawande includes examples of his own failings in this area.) Besides, they’ve been trained to want to find cures, attack problems—to win. But victory doesn’t look the same to everyone, he asserts. Yes, “death is the enemy,” he writes. “But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee... someone who knows how to fight for territory that can be won and how to surrender it when it can’t.” In his compassionate, learned way, Gawande shows all of us—doctors included—how mortality must be faced, with both heart and mind. – Sara Nelson--This text refers to an alternate Paperback edition.
“Being Mortal, Atul Gawande's masterful exploration of aging, death, and the medical profession's mishandling of both, is his best and most personal book yet.” ―Boston Globe
“American medicine, Being Mortal reminds us, has prepared itself for life but not for death. This is Atul Gawande's most powerful--and moving--book.” ―Malcolm Gladwell
“Beautifully crafted . . . Being Mortal is a clear-eyed, informative exploration of what growing old means in the 21st century . . . a book I cannot recommend highly enough. This should be mandatory reading for every American. . . . it provides a useful roadmap of what we can and should be doing to make the last years of life meaningful.” ―Time.com
“Masterful . . . Essential . . . For more than a decade, Atul Gawande has explored the fault lines of medicine . . . combining his years of experience as a surgeon with his gift for fluid, seemingly effortless storytelling . . . In Being Mortal, he turns his attention to his most important subject yet.” ―Chicago Tribune
“Beautifully written . . . In his newest and best book, Gawande . . . has provided us with a moving and clear-eyed look at aging and death in our society, and at the harms we do in turning it into a medical problem, rather than a human one.” ―The New York Review of Books
“Powerful.” ―New York Magazine
“Atul Gawande's wise and courageous book raises the questions that none of us wants to think about . . . Remarkable.” ―John Carey, The Sunday Times (UK)
“A deeply affecting, urgently important book--one not just about dying and the limits of medicine but about living to the last with autonomy, dignity, and joy.” ―Katherine Boo
“Dr. Gawande's book is not of the kind that some doctors write, reminding us how grim the fact of death can be. Rather, he shows how patients in the terminal phase of their illness can maintain important qualities of life.” ―Wall Street Journal (Best Books of 2014)
“Being Mortal left me tearful, angry, and unable to stop talking about it for a week. . . . A surgeon himself, Gawande is eloquent about the inadequacy of medical school in preparing doctors to confront the subject of death with their patients. . . . it is rare to read a book that sparks with so much hard thinking.” ―Nature
“We have come to medicalize aging, frailty, and death, treating them as if they were just one more clinical problem to overcome. However it is not only medicine that is needed in one's declining years but life--a life with meaning, a life as rich and full as possible under the circumstances. Being Mortal is not only wise and deeply moving, it is an essential and insightful book for our times, as one would expect from Atul Gawande, one of our finest physician writers.” ―Oliver Sacks
“Gawande's book is so impressive that one can believe that it may well [change the medical profession] . . . May it be widely read and inwardly digested.” ―Diana Athill, Financial Times (UK)
“Eloquent, moving.” ―The Economist (Best Books of 2014)
“A great read that leaves you better equipped to face the future, and without making you feel like you just took your medicine.” ―Mother Jones (Best Books of 2014)
“Beautiful.” ―New Republic
“Gawande displays the precision of his surgical craft and the compassion of a humanist . . . in a narrative that often attains the force and beauty of a novel . . . Only a precious few books have the power to open our eyes while they move us to tears. Atul Gawande has produced such a work. One hopes it is the spark that ignites some revolutionary changes in a field of medicine that ultimately touches each of us.” ―Shelf Awareness (Best Books of 2014)
“A needed call to action, a cautionary tale of what can go wrong, and often does, when a society fails to engage in a sustained discussion about aging and dying.” ―San Francisco Chronicle--This text refers to an alternate Paperback edition.
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The book breaks down into roughly two sections – Part A, a critique of the elder-care system in America that relies on nursing homes, and Part B, an examination of the question : 'when do heroic measures to save or prolong lives actually make things worse, and what should be done instead?'
Part A has personal relevance to many of us with parents in nursing homes. Not a day goes by but I consider whether something different could be done for my mother, knowing that I, holding power of attorney for her advance medical directives, have the legal power to change her circumstances. Dr. Gawande abhors the same things about nursing homes that the rest of us do, which he illustrates with examples until he says 'You'd think we would have burned the nursing homes to the ground.' (p. 79) The models he cites as alternatives all require at-home caregivers, saying 'Your chances of avoiding the nursing home are directly related to the number of children you have, and, … having at least one daughter seems to be crucial to the amount of help you will receive'. He cites his grandfather who lived in India to 110 years, holding title to the family lands until his death, while his uncles in India lived out their lives to old age themselves, tending to his needs, and waiting for their inheritance. His successful examples of alternatives include the 'assisted living' arrangements that are very expensive and inadequate for people who lack the ability for self-care; group living arrangements under the supervision of a dedicated individual, and bringing plants and animals into nursing homes. That was the end of Part A and the beginning of my realization that there are still no magic answers.
Part B relates the experience of several patients of Dr. Gawande's with terminal illnesses. The question of 'when to let go' is the focus. The answer is never clear, even with a mentally competent patient, and Dr. Gawande's examples don't lead to a recipe that will serve for all circumstances. He does clearly state that people's priorities change as they perceive their time is limited, not a great breakthrough considering the old addage 'you don't miss your water until your well runs dry.' He advocates the importance of knowing in advance what measures and risks patients wish to take to prolong their lives – again, not news with the prevalence of Advance Medical Directives – and he advocates that Medicine work harder to implement those wishes in spirit as well as procedure. But he assumes that substantive conversations occur while drafting the answers to the questions posed by the Directive. In my experience, the questions are posed and answered in a vacuum, like a lawyer's office, or an admitting workstation, that avoids the reality of the answers, as if they pertain to someone else. My mother doesn't yet believe she will never leave the nursing home, and she doesn't seem to think her time is limited, and the breach between her willingness to understand those two facts and my ability to negotiate that terrain is vast. The development of a healthy mindset around the fact of our mortality that leads to the closing stages of a good ending must come from within, and a dysfuntional life will most likely lead to a dysfunctional end.
Like Lake Woebegone, where all the women are strong and the men good looking, all the patients in Dr. Gawande's examples come from essentially functional families. There is someone home to send the patient back to, or, someone nearby willing to work hard to provide care for the patient. The people in nursing homes don't have that, mostly. It is not just a question of whether a potential caregiver is too selfish to be bothered with becoming a caregiver, but also a question of the life-long autonomy that the patient claimed for themselves, needing no one, themselves caring for no one, who find out in the end they are dependent on others. Perhaps they have alienated all their potential caregivers. Perhaps they are more comfortable with a professional 'friend' than a family member, and show more respect for someone who is helpful because that's their job, than someone who has always been around like a son or a daughter. There is no miracle diet. You want to lose weight : stop eating so much. You want Grandma out of the nursing home, prepare to change your life for an indeterminate length of time. Maybe you will reach enlightenment. Maybe there is true happiness in giving up oneself for the good of another. Maybe Grandma will wreck your peaceful home.
Dr. Gawande writes well, his patient examples are interesting, he shows personal growth and a deepening understanding that appear to be sincere and believable. Just by relating his experiences, he could be helping change the mindset of medical practitioners to pay more attention to their patient's wants. A more apt title, I think, would have been Being Human with the sub-title How a Doctor Learned to Listen to Patients. He is as much a subject of the book as its topic, and his growth and experiences could stand on their own without suggesting that he has solved the problems of mortality and eldercare.
Dr. Gawande's book focuses both on medical procedures and living conditions in later life. He addresses the reality that as people near the end of life, decisions about their living situation are primarily aimed at ensuring safety at the expense of retaining autonomy, especially when adult children are making the decisions. "We want autonomy for ourselves and safety for those we love," a friend tells the author. We mistakenly treat elders as children, Dr. Gawande says, when we deny them the right to make choices, even bad choices. People of any age want the right to lock their doors, set the temperature they want, dress how they like, eat what they want, admit visitors only when they're in the mood. Yet, nursing homes (and even assisted living communities) are geared toward making these decisions for people in order to keep them safe, gain government funds, and ensure a routine for the facility.
In addition, Dr. Gawande shows how end-of-life physical conditions are most often treated as medical crises needing to be "fixed," instead of managed for quality of life when treatment has become futile. Life is more than just a stretch of years; it must have meaning and purpose to be worth living, he says. This is a familiar concept (in fact, I read parts of this book in The New Yorker), but he builds a strong case for reform through case studies, stories from his own life, and examples of how individuals are either becoming victims of, or bucking, the system. He addresses assisted suicide only briefly, but he mentions it in relation to end-of-life care. "Assisted living is far harder than assisted death, but its possibilities are far greater as well," he writes.
The good news is that some people are doing what they can to improve the well-being of elders nearing the end of their lives. He demonstrates the beauty of hospice care in the home. He tells a great story of a doctor who convinced a nursing home to bring in two dogs, four cats and one hundred birds! It was a risky proposal, but the rewards were phenomenal. It made the place, and the people, come alive. I am aware, though, that these movements rely on individuals, and only if enough people have a vision for change will it come about. For that reason, I hope this book makes a big splash!
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I will not be among them.
It is well-written-- give it that.Read more