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Being Mortal: Medicine and What Matters in the End Hardcover – Deckle Edge, October 7, 2014
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"Rebound" by Kwame Alexander
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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
“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
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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!
In this new book Being Mortal: Medicine and What Matters in the End, Gawande looks at the problems of the aging population and inevitability of death. He points out that you don't have to spend much time with the elderly or those with terminal conditions to see how common it is for modern medicine to fail the people it is supposed to be helping. In speaking of elder care he sadly points out that "Our reluctance to honestly examine the experience of aging and dying has increased the harm and suffering we inflict on people and has denied them the basic comforts they need most". Many physicians are so hell bent on preserving life that they cause horrible and unnecessary suffering.
Gawande points out that sometimes in striving to give a patient health and survival their well-being is neglected. He describes well-being as the reason one wishes to be alive. He looks at the "Dying Role" as the end approaches describing it as the patient's ability to "share memories, pass on wisdom and keepsakes, settle relationships, establish legacies and make peace with their God. They want to end their stories on their own terms." He feels that if people are denied their role, out of obtuseness and neglect, it is cause for everlasting shame.
Gawande shares his deep seated feelings in this book by revealing personal vignettes of how friends and family coped with these powerful and challenging issues. He follows a hospice nurse on her rounds. He discloses how is mother-in-law Alice's life is changed by taking up residence in a senior facility as the only reasonable option. Senior facilities and nursing homes, even the best run, are often sterile institutions that can cause psychological anguish. He includes how he dealt with the final wishes of his father. It is a melancholy yet empowering picture of a man and physician honoring his father.
Atul Gawande provides the reader with an understanding that though end of life care is inevitable there are ways to humanize the process. The patients, their families, the medical professionals are coming to terms with how to better face the decision making processes that will be, in many cases, the last decision. The subject matter is complex and sensitive but the moral of the book is that "The End Matters".