H (trying to keep up with GR friends) Balikov's Reviews > Being Mortal: Medicine and What Matters in the End

This is an excellent book. It is also the most important book that I have read in the past year.

Dr. Gawande is that rare physician who can write well and write well for the layman. There is nothing glamorous about growing old. There is nothing glamorous in taking care of those who are growing old. As to the former, Gawande, makes it clear as he describes the way our bodies decline and breakdown over time. As to the later, it helps to explain both why very few doctors are attracted to gerontology and why those who aren't are not particularly adept at dealing with those who are at or near the end of their lives.

This book is about "what matters in the end," but it is also about Gawande's journey as a physician and surgeon. "I never expected that among the most meaningful experiences I'd have as a doctor --- and, really, as a human being --- would come from helping others deal with what medicine cannot do as well as what it can."

Atul Gawande is meticulous in describing how we wear down and wear out. "There is, he told me, 'no single, common cellular mechanism to the aging process.'....The process is gradual and unrelenting." And, how many of us believe that we can put that aside for the present. "People naturally prefer to avoid the subject of their decrepitude." Yet, it colors many things that we do and many decisions that we have to make.

In his own learning process, Gawande shares his experiences, and his encounters with doctors, other care givers and physicians. "The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself."

He exposes a lot of the "nursing home approach" as insensitive with facilities that may come to resemble an asylum (in the worst sense). He explores the question, "what makes life worth living when we are old and frail and unable to care for ourselves," is its many facets. There are: basic needs for survival; need for love and belonging; desire for growth ("the opportunity to attain personal goals, to master knowledge and skills, and to recognized and rewarded for our achievements); and, perhaps, "self-fulfillment through pursuit or moral ideals and creativity for their own sake." He points out that "our driving motivations in life, instead of remaining constant, change hugely over time..."

I learned a lot about how we often treat those who cannot care entirely for themselves and how attitudes and venues are changing. When doctors are just about "tinkering" with the seriously ill, a lot is ignored. Particularly, that those people "have priorities (perhaps poorly expressed or not discussed) besides prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally alert, not being a burden to others, and achieving a sense that their life is complete."

I wish I had had this book to read before I found myself with friends and family members who were seriously ill or dying. Gawande describes how both amateur and professional caregivers can be sensitive to these issues. And, how they can give the ill and dying the opportunity to reflect on their own desires. One of those, for many, is that they would rather spend their remaining days at home instead of in an institution. There is a very illuminating section on hospice and how this should be explored far earlier than it currently is. Not necessarily invoking hospice care earlier, but being aware of what if can offer and, if desired, getting it going in time to make a difference with quality of life.

"(Though), no one ever really has control. Physics and biology and accident ultimately have their way in our lives. But the point is that we are not helpless either. Courage is the strength to recognize BOTH realities. We have room to act, to shape our stories, though as time goes on it is within narrower and narrower confines. A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one's story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone's lives."