Being Mortal

In our anesthetic world sometimes melodrama can be a way to access what we feel. When grandpa died, I wept in the shower, I took long walks engulfed by the wind. One night I lay on the kitchen floor for hours. On those tiles I learned that there is no other side of grief — loss, it just perforates us. You begin to recognize the primordial poetry of an open mouth: absence and presence in one. Growing up every time we drove by the nursing home my grandma would say a prayer. I never understood “never” like that look: her terror, her sympathy. After surrendering to it, my grief became gratitude. How lucky was I to be there? -- to witness the shaky elegance of his unbecoming? How fortunate was I to be the confidant he told about his desire to go? In his book, Gawande exposes how modern medicine has erased traditions around morality that help us understand how there are some forms of living which can be more painful than dying. With the imposition of the nuclear family over more extensive community, elder care work is outsourced to sterile and isolating institutions. Gawande questions Western medicine’s salvific function -- its imperative on maintaining life -- without interrogating what quality of life, and what the patient wants in the first place. Doctors are trained in the technicalities of aging — accumulation of lipofuscin, DNA mutation — but not the affects of it. He encourages us to imagine another form of medicine: one in which we ask people what gives their lives meaning? It’s the distinction between living and existing. Health just can’t be about the body, it has to consider the psyche. Ultimately, I was able to accept my grandpa’s death because I knew that prolonging his life would mean incalculable suffering: the inability to speak, write, read, all very things that he loved. Read this not for comfort, but for conviction. His book is less dynamic to read as it is to apply and propel conversations that have been put off. Occasionally his provocations outrun his prose and his compassion gets lost with so many case studies. But it’s important in the way confronting inconvenient things are: it’s less about the beauty, and more about the lesson.

"Being Mortal: Medicine and What Matters in the End" by Atul Gawande is a compelling exploration of aging, death, and the medical profession's approach to these inevitable aspects of life. Gawande, a surgeon and medical writer, combines personal anecdotes, patient stories, and research findings to address the shortcomings of modern medicine in dealing with mortality. Here are ten key lessons and insights from the book: 1. The Limitations of Medicine: Gawande emphasizes that while medicine has made significant advancements in prolonging life, it often falls short in addressing the quality of that life, especially as patients face terminal illnesses. He argues that the focus should shift from merely extending life to enhancing the quality of life in one’s final days. 2. Understanding Aging and Dying: The author discusses the natural processes of aging and dying, highlighting that these stages of life are often misunderstood and poorly managed. He encourages readers to confront the realities of aging and death, fostering more open conversations about what it means to live well in the face of mortality. 3. The Importance of Autonomy: Gawande stresses the significance of autonomy in making healthcare decisions, especially for the elderly and those with serious illnesses. He advocates for a patient-centered approach that respects individual preferences and values, allowing patients to have a say in their treatment and end-of-life care. 4. Palliative Care: The book highlights the benefits of palliative care, which focuses on providing relief from pain and other distressing symptoms, rather than solely aiming for a cure. Gawande illustrates how palliative care can improve the quality of life for patients with serious illnesses and offers a holistic approach to treatment. 5. The Role of Family and Caregivers: Gawande underscores the vital role that family and caregivers play in the lives of the elderly and terminally ill. He discusses the emotional and logistical challenges they face and emphasizes the need for support systems that address both patient and caregiver needs. 6. Creating Meaningful Conversations: The author advocates for more meaningful conversations between healthcare providers and patients regarding end-of-life options and preferences. He encourages doctors to ask patients what matters most to them, rather than solely focusing on clinical metrics or survival rates. 7. Living with Purpose: Gawande emphasizes the importance of living with purpose, even in the face of terminal illness. He shares stories of patients who found ways to engage in activities that brought them joy and fulfillment, illustrating that a meaningful life can continue until the very end. 8. The Dangers of Overmedication: The book addresses the issue of overmedication, particularly among the elderly. Gawande warns that aggressive treatments and medications can often lead to diminished quality of life and increased suffering, urging a more thoughtful approach to prescribing and treatment plans. 9. Reevaluating the Role of Nursing Homes: Gawande critiques the traditional model of nursing homes, which often prioritize safety and efficiency over the well-being and autonomy of residents. He discusses innovative models that create more homelike environments, fostering a sense of community and dignity for older adults. 10. Embracing Mortality: Ultimately, Gawande encourages readers to embrace the reality of mortality. He argues that by acknowledging death as a natural part of life, individuals can cultivate a deeper appreciation for the time they have and make choices that reflect their values and desires. "Being Mortal" by Atul Gawande offers profound insights into the complexities of aging, dying, and the medical profession’s role in these processes. Through his exploration of autonomy, palliative care, and the importance of meaningful conversations, Gawande advocates for a more compassionate and understanding approach to mortality, emphasizing that the goal of medicine should be to help people live well until the very end.

In Being Mortal, author Atul Gawande tackles the hardest challenge of his profession: how medicine can not only improve life but also the process of its ending Medicine has triumphed in modern times, transforming birth, injury, and infectious disease from harrowing to manageable. But in the inevitable condition of aging and death, the goals of medicine seem too frequently to run counter to the interest of the human spirit. Nursing homes, preoccupied with safety, pin patients into railed beds and wheelchairs. Hospitals isolate the dying, checking for vital signs long after the goals of cure have become moot. Doctors, committed to extending life, continue to carry out devastating procedures that in the end extend suffering. Gawande, a practicing surgeon, addresses his profession's ultimate limitation, arguing that quality of life is the desired goal for patients and families. Gawande offers examples of freer, more socially fulfilling models for assisting the infirm and dependent elderly, and he explores the varieties of hospice care to demonstrate that a person's last weeks or months may be rich and dignified.

Atul Gawande is author of three bestselling books: Complications, a finalist for the National Book Award; Better, selected by Amazon.com as one of the ten best books of 2007; and The Checklist Manifesto. His latest book is Being Mortal: Medicine and What Matters in the End. He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Executive Director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit organization making surgery safer globally. He and his wife have three children and live in Newton, Massachusetts.

***UPDATE*** DR Gawande has been appointed to Biden's COVID team. An outstanding physician...and this book is brilliant*** Happy for you Americans. I can't emphasize enough to read this one. I'd give it a triple star if I could. Simply put: This is a book about dying. But, on one's own terms. Gawande boldy argues that the medical world has got it wrong when it comes to the treatment of the dying. The objective of medicine should not be to ensure health and survival; rather it should be about the quality of life and what it means to die with dignity, a sense of purpose, and most importantly, control over one's life. It's about being able to write the final chapter the way you want to and to enable well-being in the sense one wishes to be alive. It's considering hospice vs emergency room care. What an unpleasant topic, but WHOA, what a relevant one! Through a series of interviews with seniors and the terminally ill, he asks them what means the most to them; what are they willing to sacrifice and what they won't, in order to extend their life a little longer. He examines how the dying were treated historically to the cultural, traditional institutionalized view we have now. Written humanely by an emergency physician who in my opinion, has got it so right. I can only hope to have a physician as intuitive and caring as he, as I shape my ending chapter. 5* read.

Update: $3.99 kindle download today. If you missed this book… And I can’t imagine that many people have missed reading it..... it’s an extraordinary book to read. I’ve been a fan of Atul Gawande since reading “Complications” with my local book club many years back --where 35 people showed up to 'express'. Our monthly Saturday's meetings are limited to 25 members of our 500+ Bay Area Book club --but members were didn't care --they were coming! After finding extra chairs --we sat down for one of the most emotionally-connected-book club discussion to date. There must already be at least 1,000 4 and 5 star reviews on Amazon --and it that does not speak for itself by now --then I don't know what does. Even though I bought this book the day it came out --I had other reading to do (still do) -- Then my husband had his accident --(which began feelings of a trial run for some gut-facing-facts-of-life). Plus, last year I was diagnosed with 'two' autoimmune diseases -- which I know damn well I struggle with it silently and privately while I also hippity-hop out into the world each day. Yet, I'm at peace --(come concerns;I'm not a total saint) --but life doesn't hurt as much as when I was a "young-strong-lean-mean-muscle-fighting-the-world-machine". Several reviews have been about readers personal connection with illness and death, written with dignity, courage and deeply felt. Others were about choices for treatments and nursing homes, and our healthcare system. One reviewer reminds us, "EVERYONE WHO IS GOING TO DIE SHOULD READ THIS BOOK". ALL REVIEWS I'VE READ HAVE BEEN FIRST RATE ....(written with feelings of passion) Since Atul Gawande always seems to have balance in his books --(life, love, and loss)-- I want to share something positive written about aging. And , please, read other reviews --and I also can't stress strong enough.: Atul has written a searingly honest book. He lets us see the impact of serious illness, and death, while at the same time captures the resiliency of the human spirit. Research has found: "Far from growing unhappier, people reported more positive emotions as they age. They become less prone to anxiety, depression, and anger. They experienced trials, to be sure, and more moments of poignancy--that is, of positive and negative emotion mixed together. But overall, they found living to be more emotionally satisfying and stable experience as time passed, even as old age narrowed the lives they led." "Being Mortal" is beautifully written. Atul Gawande, teaches us something important about how to live with the time we have.

Being Mortal tackles the all too uncomfortable subject of mortality, and what it means to live and die well in life's last moments. In our modern world of medicine and technology, hospitals and doctors can always do more, but is more surgery or therapy always the right step at the end of life when positive outcomes are unlikely and severe side effects are guaranteed? For me, the most eye-opening and useful parts of the book are those comparing the different types of care that someone can receive as they reach end of life, including palliative care, assisted living, nursing home, and hospice. I also appreciate that the book looks at this emotionally-distressing time from the perspective of both the person coming to the end of their life, as well as from that of their loved ones. Often, our impulse is to do everything we can to prolong life, but this book makes a strong case for quality now over quantity later, so that purpose and meaning can be preserved for as long as possible. The book did feel over-simplified though. For example, the people in here with access to all the choices were either old enough to qualify for Medicare, young with good insurance, or lucky enough to find an affordable plan that provided quality care. But in the real world, that often isn't the case. Another example is that the dying person, as well as their loved ones, were reasonable people who are self-aware and communicated openly. But when dealing with relatives, that often isn't the case. While this book is a great kicking off point for starting discussions and forming a plan, it certainly doesn't provide any concrete answers or even can act as a guide. Dying is a personal thing, fraught with perilous decisions and messy emotions, just like living is. What works for one person doesn't necessarily work for another. For such a difficult subject, I felt myself swept along in Dr. Gawande's eloquent writing and compassionate storytelling. I go away having learned a lot, but also feeling a little disappointed (unfair, I know) that this book did not provide me with more concrete answers to life's difficult questions.

If you’re not afraid of dying, you’re either lucky or lying. Meanwhile, this book gave me the heebee-jeebees! Did I really need to know that as I age my aorta will get crunchy and my shrinking brain will rattle around in my skull? Or did I need to know (and perhaps forever visualize) the disgusting details of the downhill spiral of my teeth and feet, and what I’ll have to show for them? Don't worry, the author does not dwell on these things, but I do! And, oh, how I hope I'm not one of the 40% (!) who is toothless by the time I'm 85, if, of course, I live that long. And do I even want to live that long after reading this depressing book???! Johnny Depp says he wants to be on a morphine drip and just drool and nod. I’m with him. So actually, this book did help me figure out how I want to go out, if I get the choice. I guess going into this, I thought it would be a how-to book, how to not be scared of dying. Instead, I got a terrifying view of the horrors of nursing homes, terminal illness, aging, and deathbeds, and a blow-by-blow account of my bodily deterioration and decay. It is not a pretty picture. It is worse than my over-active imagination can even conjure up. Informative? Yes, in spades. And this doctor can write! Clear, captivating prose. I learned so much about how doctors and other caregivers think of and handle the elderly and terminal patients. It talked about how people cling to hope even if their case is hopeless, and how doctors are often unable to tell it to them straight. And about how doctors, despite their knowledge about the facts, often hold out hope for a miracle too. Other good stuff: -Liked the many stories of people thriving in assisted living places. The people were real, their stories fascinating in a quiet way. -The author is compassionate and has a conversational tone—very undoctor-like. -Liked learning about what hospice does exactly and about how much they can help out. -Liked that a provider had the bright idea to bring in other living things—plants, dogs, and kids—to assisted living places and loved hearing about how the residents responded so well. Stuff I didn’t like: -Too much history about assisted living, and too many pioneers mentioned by name. I get it that the author wants to give them credit, but we readers won’t remember a single one. Maybe some of this info would have better in an Acknowledgment section? -The author claims that people get more mellow with age. What? Then why are so many old people on anti-depressants and anti-anxiety meds? Stuff I wanted: -Wanted it to be more psychological. -Wanted more discussion about the fear of death, and a mention of how religion plays a part. -Wanted talk about the cost of medical care. Does insurance always pay for chemo, for example? Do families go bankrupt? How much do finances affect the decision of whether to continue with treatment? -Wanted a secret formula for shooing away the fear of death and dying. Funny, I was way more comfortable reading about young people with terminal illnesses than about old people about to die. I can handle reading about suffering that can’t happen to me; I’m calmly empathetic. But tell me about someone my age (65) or older who has just been diagnosed as terminal, and I squirm and twitch out of sight. Just give me the clicker and let me watch Louis C.K., will you? All fears and gripes aside, I know this is an important book, and it’s an amazing one. The doctor is talking about the elephant in the room, which is cathartic, depressing, and anxiety-producing all at once—you might want to have your valium handy. I do think this book will be scary to read if you're in your 60s or older. That is, unless you’re lucky or lying.

Being Mortal: Medicine and What Matters in the End, Atul Gawande Being Mortal is a meditation on how people can better live with age-related frailty, serious illness, and approaching death. Gawande calls for a change in the way that medical professionals treat patients approaching their ends. He recommends that instead of focusing on survival, practitioners should work to improve quality of life and enable well-being. Gawande shares personal stories of his patients' and his own relatives' experiences, the realities of old age which involve broken hips and dementia, overwhelmed families and expensive geriatric care, and loneliness and loss of independence. In the beginning of the book he explores different models of senior living, including concepts such as poorhouses, multi-generational households and nursing homes. Gawande explores personal stories as well as accounts from geriatric doctors such as Keren Brown Wilson, an originator of the assisted living concept. He ruminates on stories of people dealing with age-related frailty, serious illness and death, and his own confrontation with mortality. ...

This is probably the most important book on mortality I've ever read. It is packed full of information and written in easily comprehendible language, in fact, very personal language. There is so much information here I had a hard time reviewing as I want to share it all! Promise, I won't, but will try to stay with just a few important highlights. First, this book looks at nursing homes and the rise and fall of assisted living. You may think, what? We have assisted living. But, for a short time after people no longer simply died at home, assisted living, through the hard fought battles of one woman in particular was available to all patients. Now the primary goal of safety has once again given us nursing homes. Assisted living is mostly for those with the money to afford it. This need for safety has left many to languish at places no different than former asylums. This so called "life" is devoid of any purpose to live, and actually increases death rates. This book then goes into the medical profession. The focus here is on repair, how to fix, what medications will work, when is surgery necessary. The only problem is that the medical profession has no idea how to talk to people, and is even discouraged from doing so. Most doctors have not had a single course in geriatrics. What to do with an old person? Amazing that we have no sense of our own mortality. Now 25% of Medicare spending is for 5% in their final year of life, with very little benefit. A great quote was "We imagine that we can wait until doctors tell us there is nothing more they can do, but rarely is there nothing more that doctors can do." So this instance of survival at all costs has left many to die in a hospital with tubes everywhere, fading in and out of awareness. This of course leaves no chance for good-byes, even "I'm sorry" or "I love you." What it really comes down to is a few important questions. I loved the ones provided in this book. "The biggest questions to ask are, what are your biggest fears or concerns? What goals are most important to you and what trade-offs are you willing to make, or not make?" Another topic was hospice. I assumed hospice is only for the final end of life, but it is not. Hospice is available at any time, and the focus is on a person's wants and needs. Many get better after a stay, and leave, some even return to work! Incredible book. Atul Gawande is a physician who I believe has written a most timely and important book. He provides an inside look at medicine, a historical perspective on dying, the most recent surveys on cost and care options and so much more. He comes from his own experiences and clearly his research has changed his own outlook on mortality. A must read. Highly recommended!

A clear, uplifting, and eloquent education on the deficiencies of the medical establishment in end-of-life care and promising progress toward improvements. This Boston surgeon has already authored accessible books on the human art behind the science of medicine with his “Complications” and “Better”. He is a master at using stories of his cases to address disparities between our expectations and the reality of medical practice and drawing on diverse research to advocate for needed changes. Here he delves into the tragedy of so many people at the end of their life dying in the depersonalized, institutional conditions of hospitals and nursing homes. In in his own training he was taught to see death as the enemy to fight at every step with everything in the arsenal of medicine and didn’t conceive any role for doctors in facilitating help with the dying process. He does remember a seminar in which they read Tolstoy’s “The Death of Ivan Ilyich”, which highlighted the benefits the character gained from simple, humane interactions with his servant. But that lesson was soon forgotten. Only when some of his surgical interventions came to a bad end of complications and a miserable death in the ICU did he come to consider changing how he approached his cases. For one man with cancer invading the spinal cord, he successfully removed enough to delay the onset of paralysis, but he never recovered from the procedure. Such failures led the good doctor to rethink is ingrained approaches: The chances that he would return to anything like the life he had even a few weeks earlier were zero. But admitting this and helping him cope with it seemed beyond us. We offered no acknowledgment or comfort or guidance. We just had another treatment he could undergo. Maybe something good would result. … We pay doctors give chemotherapy and to do surgery but not to take the time required to sort out when to do so is unwise. This certainly is a factor. But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is … The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war 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, someone who understands that the damage is greatest if all you do is battle to the bitter end. In a set of brief chapters, Gawande adroitly covers innovations in making nursing homes more humane, the advent of assisted living solutions, and growth in palliative care and hospice services. Simple approaches like allowing nursing home residents have pets or opportunities to socialize with kids in a nearby afterschool program had surprisingly powerful benefits. The power of assisted living programs to preserve privacy and autonomy while fostering socialization and sense of community is illustrated with exemplary stories. From a low point of just 17% of people dying at home in the 80’s, by 2010 fully 40% were being supported at the end through hospice care, of which half involved a home location. Studies revealed that patients who stopped chemo sooner and entered hospice sooner had less suffering at the end and lived up to 25% longer. The outcome had Zen aspect in that “you live longer only when you stop trying to live longer”. Just family communication about end of life care decisions by palliative care providers had a huge impact on reducing costly ER and ICU utilization. The lesson the Gawande learned and began applying to his patients (and the situation of his own father) was to take the time to find out what gives the person a sense of meaning and purpose in life and to explore the trade-offs they are willing to make to best fulfill those goals relative to the risks of procedures aimed at giving them a longer life. But the challenge remains in every case to guide his patients on when to stop the pursuit of treatment in favor concentrating on living the best they can with what they have left. The case of a hero of mine, biologist Stephen Jay Gould, facing a fatal lung disease, mesothelioma, is telling. In an essay “The Median Isn’t the Message” he notes how variation around the median survival of 8 months included a long tail of minority cases with longer survival, a situation luck placed him with (he lived 20 years more before succumbing to an associated lung cancer): ”Of course I agree with the preacher of Ecclesiates that there is a time to love and a time to die—and when my skein runs out I hope to face the end calmly and in my own way. For most situations, however, I prefer the more martial view that death is the ultimate enemy—and I find nothing reproachable in those who rage mightily against the dying of the light.” What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and with only the rudiments of a system to prepare patients for the near certainty those tickets will not win. Hope is not a plan, but hope is our plan. After exploring the insights of social scientists such as Goffman, Maslow, and Dworkin, he arrives at some important concepts that providers and families of the seriously ill should keep foremost in mind: Whatever the limits and travails we face, we want to retain the autonomy—the freedom—to be the authors of our lives. This is the very marrow of being human. … This is why the betrayals of body and mind that threaten to erase our character and memory remain among our most awful tortures. The battle of being mortal is the battle to maintain the integrity of one’s life—to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe their job is not to confine people’s choices, in the name of safety, but expand them, in the name of living a worthwhile life. … Most often, these days, medicine seems to supply neither Custers nor Lees. We are increasingly the generals who march the soldiers onward, saying all the while, “You let me know when you want to stop.” People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come—and escape a warehoused oblivion that few really want.

* Originally reviewed on the Night Owls Press blog here. * I was first introduced to Atul Gawande's writing in his "Annals of Medicine" column for The New Yorker magazine. He wrote a thrilling piece about a woman with an itch—an itch so strong, so persistent, it was beyond belief. It stumped all of her doctors. Medications didn't work. MRIs and nerve tests revealed nothing conclusive. One night, the woman woke up to fluid dripping down her face. As if in some B-horror movie, Gawande eventually reveals that she had scratched through bone, through her very own skull, into her brain. Delving into neuroscience and how our brains work and the nature of perception, Gawande wrote a piece as compelling as a forensic thriller. It wasn't just a dry reporting of medical cases and scientific findings. Gawande quoted lines from Dante's Inferno. It read like a story. Atul Gawande's Being Mortal Medicine and What Matters in the End is less an out-and-out thriller and more a personal meditation on modern medicine and how it has treated illness, aging, and dying. Being Mortal pulls back the veil on the institutions that treat the terminally ill and aging. It is a clear-eyed exploration of the sad business of dying and our bodies falling apart, taking us on a tour of gerontology, nursing homes, intensive care units, assisted-living facilities, and multigenerational homes. It is also a calm critique on medicine. He writes: "Medical professionals concentrate on repair of health, not sustenance of the soul. ... It's been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs." Gawande's message: The experiment has failed. Twenty-first century medicine can do miraculous things. But in dealing with end-of-life issues, modern medicine has been dismal. Quality of life has been the most overlooked metric in medical treatments. The measure of success for doctors is prolonging life, even if those extra days, weeks, months are miserable and and full of pain. But according to Gawande it's not the fault of doctors or patients. It's an entire culture we've built up: how we think of and treat the elderly, how everyone expects doctors to do everything it takes, to offer and try every medical procedure possible to slow down the inevitable. And there is a lot to fear, too—not just in the inevitable—but in the choices we're given. Gawande doesn't shy away from how this topic hits close to home. His wife's grandmother and his own father are two people who are discussed intimately throughout the book. He weaves the stories about their health and decline with the stories of other patients and colleagues. When describing how his own father struggled with the decision on whether to pursue more radiation therapy for a tumor growing in his spine, Gawande dwells on the tough decisions that needed to be made. His father had already undergone surgery to treat it, but things had taken a turn for the worse. Should he pursue more aggressive chemo, knowing the debilitating side effects that would happen? It is a question that faces many families when they sit in the doctor's office and have to weigh the tradeoffs. Having choices doesn't necessarily make it easier. At the heart of the book is a searching exploration of what the basic purpose of medicine really is. What should we be paying doctors to do? Gawande writes: "Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don't want a general [a doctor] who fights to the point of total annihilation." Fight to the bitter end… sadly, that's what most people try to do. More and more, as the population in the U.S. gets older and as we live longer, we need more doctors and nurses like Gawande who will broach discussion and say what they have seen, to tell people how death in a hospital really is, how aging really is, and prepare us for what's to come. So what needs to be done? Gawande suggests several things, and the message is clear: We need more of our institutions and medical practitioners to believe that we shouldn't limit people's choices in the name of safety but expand them, in the name of living a worthwhile life. We see this in the later chapters when we meet more enlightened practitioners and how they take a more patient-centric approach rather than a paternalistic one. There is a wonderful anecdote that involves a colorful menagerie and an idealistic country doctor. While Gawande is critical and often frames his exploration of medicine in big socioeconomic and cultural terms, his arguments don't take sides. He doesn't write to bully or polarize; instead, he takes a deliberate, sometimes plodding "middle road." I sometimes wished he would be more scathing of some of the atrocious experiences he hears about and even witnesses. He doesn't loudly condemn bad decisions that were made in prescribing care or stripping away an elderly person's autonomy. Instead, what he is good at is to acknowledge uncertainty and ambiguity. All of us have underestimated the human element in medicine in some way. An intense, thought-provoking read that made me more mindful about life—and the march toward the inevitable. [Disclaimer: I received an ARC of this book from the publisher for an honest and candid review. This review was originally written for LibraryThing Early Reviewers.]

This excellent book is about how medicine treats patients as their lives come to an end. Today, Western medicine is all about keeping the patient alive, no matter the cost. The problem is that all too often, treatments at the end of life have limited value; they have little potential to prolong substantially, and even if they do, the quality of life is degraded significantly. Gawande, a practicing surgeon argues that the waning days of our lives "... are spent in institutions--nursing homes and intensive care units--where regimented, anonymous routines cut us off from all the things that matter to us in life." As the end draws near, some doctors go into an "informational mode". They give their patients a list of possible treatments, potential outcomes and side effects. It is really a mountain of information and very difficult for a suffering patient--or a family--to process and make a useful decision. Gawande describes a better approach. He writes about how some doctors will talk to their patients about their goals; realistic goals, given their illnesses. They take one or two hours to understand what is important to their patients, and then bring to the forefront a treatment option that will get them closest to their goals. The most important thing for every human is "... to retain the autonomy--the freedom--to be authors of our lives. This is the very marrow of being human." Terminally ill patients who had discussions with their doctor about end-of-life preferences were far more likely to die at peace, and to spare their family anguish. Gawande writes at length about assisted living and nursing homes. Too often, these institutions seem to believe that their primary job is safety. But, fortunately, an increasing number of these institutions "... believe their job is not to confine people's choices, in the name of safety, but to expand them, in the name of living a worthwhile life." So often, terminally ill cancer patients who had intensive interventions had a much worse quality of life in their last week, compared to those who did not have interventions. Moreover, six months later, their caregivers were three times more likely to suffer major depressions! So, Gawande describes the recent institution of hospice care. "The difference between standard medical care and hospice is not the difference between treating and doing nothing .... The difference was in the priorities. In ordinary medicine, the goal is to extend life. We'll sacrifice the quality of ... existence now--by performning surgery, providing chemotherapy, putting you in intensive care--for the chance of gaining time later. Hospice deploys nurses, doctors, chaplains and social workers to help people with a fatal illness have the fullest possible lives right now ... they focus of objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as feasible, or getting out with family once in a while." Studies show that patients who choose to supplement regular oncology treatments with palliative care stopped chemotherapy sooner, entered hospice care sooner, had less suffering--and lived 25% longer! On average, doctors overestimate the time remaining for terminally ill patients by 30%. In addition, 40% of oncologists offer treatments they believe will not work! They worry about being too pessimistic, not about being too optimistic. Gawande describes experimental programs that give patients and their families a false hope. But these experimental treatments often have debilitating side effects with very little chance of working. Gawande writes that our medical system and culture is built around the "long tail" of an improbable long life after a cancer diagnosis. The multi-trillion dollar medical system is the equivalent of lottery tickets. The problem is the system does not "... prepare patients for the near certainty that those tickets will not win." Gawande adds wonderful personal touches throughout the book. Through a number of anecdotal histories, he traces the end-of-life treatments and outcomes. He even details the final months, weeks and days of his father's life. He shows clearly how much better it is for terminally ill patients to communicate with their doctor, to let their doctor understand their goals, get the right type of advice, and to understand when it is best to "let go".

Depressing, but necessary to consider and talk about. What's the one unfortunate thing everyone on this planet has in common right now? We will all eventually die one day. So knowing that eventuality, why do we not plan for and discuss how we want to spend our final years/months/weeks/days? If we are fortunate enough to go the way of a steady decline via old age, how can we maintain our enjoyment of life as we become less able to meet our own needs independently without burdening our loved ones? If faced with a terminal prognosis, how do you weigh interventions that can possibly extend quantity of life versus those that can extend quality of life? These questions and more are covered in this book, with sobering real life examples, some of which come from the author's own family. I found this book to be informative and hopefully useful at some point in the very distant future. A must read for everyone, though perhaps delay doing so if there has been a recent death in your life, as this would probably be harder to read emotionally.

A very eye opening book on aging, what happens as we age, and where do we go, when we can no longer take care of ourselves. This book asks some very interesting questions, makes one really think about the importance of making these decisions while one is still able. What is important to us, what are we willing to give up, are some of those questions. The writing is clear, and concise, the information extensive but not at all confusing. The people whose life's are presented are treated as real people, not just case studies. One person is very close to the author and we see all the decision making that goes into his final acceptance. Sad, yes sometimes, but we are all going to age, no matter where we live and this book covers so much. I consider it a must read, a gaining of intelligence and a new way of looking at many things. Wonderful book.

I appreciated Atul Gawande’s message that we should talk more about death and dying earlier on in our lives instead of avoiding the subject. His deep dive into the stories of elderly people living in nursing homes/assisted living helped me gain greater knowledge about what end-of-life scenarios may look like. I walked away from this book understanding more about the importance of autonomy and meaning for elderly people. I also did get a bit teary-eyed reading about Gawande’s father’s passing. My two main critiques of this book center on its writing style and its lack of attention to sociocultural factors. First, the actual writing of Being Mortal felt so dry to me – the topics are of great importance, yet I felt like the tone vacillated between journalism and creative nonfiction and didn’t really land on either. Second, I found it odd that Gawande didn’t discuss or at least mention cultures in which talking about grief and death are more normalized (e.g., Native American culture). Furthermore, he didn’t discuss how lack of access to healthcare due to socioeconomic constraints or other barriers (e.g., racism in healthcare) affect issues of death and dying. Even a paragraph that honored these important factors would have elevated this book for me.

t took me months to find the courage to read this. I know it is silly to be scared of a book, but the topic of mortality is so depressing that I dreaded reading it. I had even checked out the book from the library several times, read a page or two, and then promptly returned it, thinking I would try again at some undetermined date, when I was a more evolved human being and better able to cope with illness and death and dying. (Future-Diane is very assertive and poised, apparently.) But this book continued to niggle at me. I felt obligated to read it because I suspected it could help me cope with aging relatives. And yet I resisted, weeks turning into months. The solution was found in an audiobook. I've discovered that listening to audiobooks on my daily commute is an excellent way to get into works I might otherwise not have the patience or fortitude to read. You can imagine my relief when this book turned out not to be scary at all. In fact, it was a bit bland. It begins well enough: "I learned about a lot of things in medical school, but mortality wasn't one of them." Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the process of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it. Gawande explains that historically, the elderly lived with extended families and died at home. This was the way it worked for hundreds of years. But the more a country industrializes, the more change occurs. Now the common practice in America is for the elderly to be moved into nursing homes or assisted-living places. Some still live with families, but eventually, it becomes a medical issue. Increasingly large numbers of us get to live out a full life span and die of old age. Old age is not a diagnosis. There is always some final proximate cause that gets written down on the death certificate — respiratory failure, cardiac arrest. But in truth no single disease leads to the end; the culprit is just the accumulated crumbling of one's bodily systems while medicine carries out its maintenance measures and patch jobs. We reduce the blood pressure here, beat back the osteoporosis there, control this disease, track that one, replace a failed joint, valve, piston, watch the central processing unit gradually give out. The curve of life becomes a long, slow fade. Gawande discusses the history of assisted-living places and nursing homes, and mentions research that shows ways to improve the quality of life for patients, such as giving them responsibility (taking care of a pet or plant, for example) and making sure there is enough social activity in the building. He also shares numerous stories of patients and how they coped with illness or end-of-life practices. This is where my interest started to wane -- there were just too many cases, and the book felt padded. I wondered if the whole book could have been edited down into a New Yorker-type magazine article, which would have been more efficient and effective. My favorite section was when Gawande shared the story of his father's illness, and how that was handled. His father was a respected surgeon, and when he was diagnosed with brain cancer, some profound decisions had to be made. Gawande is a good writer and is skilled at explaining medical terms and processes to the layperson. Here he also shared his personal feelings, and it was quite moving. Another good section was the advice Gawande gives on talking with patients about what their priorities are. For example, one man who was facing a serious surgery told his wife that what mattered to him was being able to watch football and eat chocolate ice cream. As long as he could still do that, he wanted the doctors to do everything they could to save his life. In another example, Gawande's father said it was still important for him to be able to visit with people, and he was scared of becoming paralyzed. Talking with someone about what they value most in life can assist with making better medical choices. I would recommend Being Mortal to those interested in reading more about end-of-life decisions. And don't be scared -- this book doesn't bite.

Favorite Story [Gawande's father wanted his body cremated and his ashes spread in the Ganges River, which is sacred to Hindus, so a few months after his death the family traveled to Varanasi] "As the oldest male in the family, I was called upon to assist with the rituals required for my father to achieve moksha -- liberation from the endless earthly cycle of death and rebirth to ascent to nirvana. The pandit twisted a ring of twine onto the fourth finger of my right hand. He had me hold the palm-size brass urn that contained my father's ashes and sprinkle into it herbal medicines, flowers, and morsels of food: a betel nut, rice, currants, rock crystal sugar, tumeric. He then had the other members of the family do the same. We burned incense and wafted the smoke over the ashes. The pandit reached over the bow with a small cup and had me drink three tiny spoons of Ganga water. Then he told me to throw the urn's dusty contents over my right shoulder into the river, followed by the urn itself and its cap. 'Don't look,' he admonished me in English, and I didn't. "It's hard to raise a good Hindu in small-town Ohio, no matter how much my parents tried. I was not much of a believer in the idea of gods controlling people's fates and did not suppose that anything we were doing was going to offer my father a special place in any afterworld. The Ganges might have been sacred to one of the world's largest religions, but to me, the doctor, it was more notable as one of the world's most polluted rivers, thanks in part to all the incompletely cremated bodies that had been thrown into it. Knowing that I'd have to take those little sips of river water, I had looked up the bacterial counts on a Web site beforehand and premedicated myself with the appropriate antibiotics. (Even so, I developed a Giardia infection, having forgotten to consider the possibility of parasites.) "Yet I was still intensely moved and grateful to have gotten to do my part. For one, my father had wanted it, and my mother and sister did, too. Moreover, although I didn't feel my dad was anywhere in that cup and a half of gray, powdery ash, I felt that we'd connected him to something far bigger than ourselves, in this place where people had been performing these rituals for so long."

Not many of us relish the idea of growing old, our bodies slowly breaking down, becoming weaker and weaker. Losing your teeth and your eye sight dimming. Having aches and pains and trouble getting out of bed. Your memory and thought processes declining, becoming less and less clear. There is not much fun in this and yet far fewer of us would prefer the alternative -- to not age, to die young. Depressing but important and informative, Being Mortal: Medicine and What Matters in the End is about the aging process and our mortality. Dr. Atul Gawande discusses what happens as we age and how we in the West treat the elderly. He argues that quality of life should be the medical profession's aim. When there is no cure for a person, why use every possible treatment to prolong a person's life at the expense of the quality of the time they have left? He calls for a change in how we handle old age and the end of life in order to cause less suffering, even if it means the person will have a few months fewer to live. Doctors, not wanting to admit defeat, will often recommend procedures and surgeries that will cause no small amount of suffering. The patients and their families, thinking there is some hope after all, often agree to these treatments. Instead, we should aim to lessen suffering, and to allow people to die with as much dignity as possible. This book really opened my eyes to what it's like to be in a nursing home. For most patients, they are basically a prison. Unfortunately, many people become unable to stay at home alone or to take care of all their own basic needs and end up in one. Dr. Gawande discusses alternative homes and hospice, which are much more compassionate and that let the elderly feel more comfortable. I could have done with fewer human interest stories and more facts, as he talks about many individuals and relates their stories. There was quite a bit of repetition because of this and so I think maybe 3 or 4 people's stories would have been sufficient. I loved all the facts, depressing as they are. Unless we die young, we are all going to one day become old. Our bodies and brains will deteriorate, weakening and worsening until we finally succumb to death. Not much fun about that. However, thinking about these things ahead of time, we can prepare for the time when we no longer can take care of ourselves. We also can become more compassionate towards those who are already elderly. We can change how we treat them, becoming more compassionate in the process. This is an important book for all of us to read, but don't expect to feel an overabundance of joy whilst doing so.

Being Mortal: Medicine and What Matters in the End The final words in this title What Matters in the End could as easily be a statement as a question and sets the theme for this exploration of living and dying. Mortal we are and yet its hard to embrace this concept especially when we are closer to our end than at its beginning. It may be true that we do not know when we’re going to die but frankly some of us know it will be sooner than later. We plan for so many things in our lives yet leave this most needed planning, that of the way we wish to die, what matters in the end, left unspoken, left undone. Atul Gawande is to be commended for sharing stories of his patients and family as they seek the answers to the questions of life’s final moments. As a doctor he felt he was treating the illness but not the person, often afraid to say there is nothing more I can do for you. By changing the way he saw his role he came to the understanding that medications and operations may not be the best course of treatment but that he could continue in other ways to help his patients. He learned that it is important to talk to with his patients, ask questions, and most of all to listen. The patient first but also the family needs to be heard. Gawande learned to ask these four questions of those in his care: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What trade-offs are you willing to make and not willing to make? What is the course of action that best serves this understanding? Ask yourself these. Can you answer them honestly? Do you think they might change as your situation does? I can only hope if I were ill that someone would ask me the first two questions. The third and fourth are harder to answer. One patient of Gawande’s answered that if he could eat chocolate ice cream and watch football he would be happy. These were his trade-offs that sound simple and yet even these two small things might be more complicated than one would think. Being Mortal it is not an easy book to read but there is hope and even laughter in its pages. There is also optimism in our approach to assisted living choices, hospice care and our living with our elderly. Besides giving me some food for thought regarding my own priorities Being Mortal will open new discussion with my husband regarding his, and ease the road to discussion of our plan with our children. Surprisingly reading Being Mortal provided a better understanding and an easing of the guilt associated with seeing my parents through their ending days. This knowledge hopefully will lead to discussion with my family of what matters to me and should make their lives easier. As I age one paramount consideration is where the next home may be and just what I am seeking in this experience. This could change quickly and I need to keep up with what’s available. I was very interested in the pioneering independent or assisted living models Dr. Gawande mentions. If you’ve ever been part of choosing one of these you will know how important this decision is and how often choices are limited. Reading about what Bill Thomas was able to achieve in a nursing home (THe Eden Alternative) in New Berlin, NY in 1991 was so uplifting. There is a whole chapter dedicated to this. Picture plants, children, dogs, cats, and 100 parakeets all living in harmony with the residents here. Might not work everywhere but what a concept. I want a place where I can live, not vegetate. One major point I took from this was that we often visit these facilities thinking we are choosing for our loved ones without really considering their needs. We look at the convenience for us. I don’t think we mean to do this but it has given me a heads-up awareness. There are many excellent reviews of Being Mortal on GoodReads and of course, elsewhere. The reading of these has prompted further contemplation and has pointed out things I might have missed. For this I thank the readers who share so much here.

***NO SPOILERS*** Being Mortal is about something no one can escape: death. That makes it an essential read for everyone. A sizable portioned also is focused on cancer, which is the second leading cause of death in the U.S. That also makes this book an essential read. Even for those who aren’t affected by the infirmities of old age or by cancer, at some point they’ll likely know at least one person who is. Whatever the case, everyone should be properly prepared to possibly make some tough end-of-life decisions. Gawande argues that medical technology has serious limitations in its ability to improve quality of life, in many instances worsening it instead. He builds the book around these uncomfortable facts of life. Something that makes Being Mortal outstanding is how feeling it is. In rich and loving detail, Gawande shares the stories of various elderly people (in the first half) and those dying from cancer (second half). It’s a very gradual unspooling, as he starts with interesting background information right through to their older years. His notebooks must have been overflowing with notes. These portrayals are intensely emotional and what make Being Mortal a page-turner. Here are real people whose major health dilemmas I felt keenly. It’s the furthest thing from abstract and dry, and when some of these people die, I felt the impact. I’m glad for it. Prior to reading Being Mortal, I lacked an emotional link to these issues, especially to cancer. Being Mortal changed that for me significantly. These true stories are Gawande’s jumping-off point to argue for a sea change in elder care and also end-of-life care for the terminally ill. Somehow, Gawande makes the topic of assisted living and nursing homes fascinating. Being Mortal isn’t just Gawande’s (professional) opinion, though. He devotes ample space to influential people in the fields of geriatrics, oncology, and hospice, in addition to citing relevant statistics and the latest research to support his perceptive and compelling arguments. He convinced me. Being Mortal is also well written and strategically organized. I had no hesitation sliding this onto my “important nonfiction” shelf after finishing and also don’t hesitate to recommend Being Mortal to all. This is another unexpected treasure of a nonfiction book that reads just like the most gripping fiction I’ve read. The grim subject didn’t matter to me; I picked up Being Mortal with such joy each time I had some free minutes to read. This isn’t a bland “nonfiction book about medicine.” It’s a book about everyday people and the ultimate humbling experience: a reckoning with their physical failings. I feel confident that anyone who appreciates a moving story with the most memorable characters will love Being Mortal. I’ll only say that I think timing in reading this is important, given the weighty topic. Although those caring for someone with cancer or in need of elder care will find Being Mortal extremely helpful, the book may compound any distress. On the flip side, for those not in this situation, I urge them to read Being Mortal as soon as possible.

Catching up… It was December 2016 when our Library Book Discussion group decided to read and discuss this book. It seemed appropriate at the time. A lot of us were dealing with either aging parents, or our own feelings about death and dying. His focus was on assisted living. I was caregiving my mother, and my husband was caregiving his father in the same assisted living environment. So, this discussion and book was very personal for me, at the time. My Mom and father-in-law have since passed on. (Interestingly, within two weeks of each other.) But I remember how helpful this book was for me, and the group of men and women who surrounded me in discussion that day. We shared how to distill what mattered most to each of us in life so that we could navigate our way toward the edge in a meaningful and satisfying way. I won’t go into the various stories that he shares about the different people through his pages, I think that is best read by readers, but he did bring up a variety of heartfelt statements that were meaningful discussion moments for us as a group. As an example… “It is not death that the very old tell me they fear. It is what happens short of death.” In our discussion, we wondered how our family would feel about telling them, “I’m ready to go” or even if we would know how we would feel when we were ready to go. It was that fine line about striking a balance between fear of death and just being ready to let go. I remember that this wasn’t an easy discussion to have with my mother. Especially as her mind began slipping from the Dementia with Lewy Bodies/Parkinson’s Disease. One day, my mother shared with me that she was afraid of her own pending death. I tried to calm her. I remember her asking me what stage she was in of Parkinson’s disease. And I tried to explain it to her as sensitively as I could. I found out that after I left, her caregiver called me and said she was in tears, because she thought she was going to die soon. I drove back to her immediately, to calm her again and reassure her that wasn’t the case. I realized then, that this was only the beginning that things were going downhill for her – mind. So much of our discussion about this book, talked about the various fears and challenges associated about end-of-life. The book asked us to consider… How can we appreciate, honor, value a life, our well-being to live and die in dignity? I certainly appreciated the experience of this book in working with my mother through her end-of-life. The author may not have all the answers in this book, but he definitely opened the conversation.

An essential guide to decision-making about end-of-life care, but also a more philosophical treatment of the question of what makes life worth living. When should we extend life, and when should we concentrate more on the quality of our remaining days than their quantity? Most of the book weighs the plight of the elderly (it’s not just grim nursing homes out there), but there are also plenty of illustrative cases about the terminally ill. The “Letting Go” chapter is among the best; it grew out of this New Yorker article, which proved extremely helpful for my sister when she was arranging hospice care for her late husband. Along with The Emperor of All Maladies, this is a book everyone should read. Surgeon Atul Gawande, like Siddhartha Mukherjee, brings a physician’s technical knowledge to his writing, but also a very personal touch: his father, grandfather, and grandmother-in-law are among his subjects. This book is truly a gift. I plan to pass it to my mother; she’s only 67, but it’s never too early to start on that ‘hard conversation’ about one’s wishes for the end of life. Favorite passage: “The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. 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, someone who understands that the damage is greatest if all you do is battle to the bitter end.”