Tuesday, December 30, 2014

Being Mortal: Medicine and What Matters in the End

Title:  Being Mortal:  Medicine and What Matters in the End
Author:  Atul Gawande
Publication Information:  Metropolitan Books. 2014. 304 pages.
ISBN:  0805095152 / 978-0805095159

Book Source:  I read this book based on an interest in the topic.

Favorite Quote:  "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."

Being Mortal takes on the conversation we so often avoid in our lives. No one wants to think of his or her own mortality, and no one wants to think of the mortality of a loved one. Yet, these conversations must happen before the decision is at hand and before conditions get such that we lose the ability to have the conversation. "This is what it means to have autonomy - you may not control life's circumstances, but getting to be the author of your life means getting to control what you do with them."

Atul Gawande takes on different elements of the issues involved with end of life care - nursing homes, hospice care, the role of medicine, the role of family, and individual choice. The book discusses these topics through the transitions that occurs in a person's life. The book's chapter titles  such as Things Fall Apart, Dependence, Assistance, A Better Life, and Courage convey the focus of the book on the individual patient - not just the facts, procedures, medicines, or institutions.

The central question at each juncture is - What is your (the patient's) goal? What is important to you? Is it to reach a milestone or event? Is it to suffer no pain? Is it to extend life as long as possible? Is it to maintain the ability to pursue a certain passion? What matters to you in the end?

The goals are of course unique to each patient and family. The book focuses on the "how."

It presents the research and the history of end of life care. It talks about the advent of nursing homes and the different approaches that have been tried to make them homes. It talks about the difference between curative and palliative medical measures. It talks about the conflicts that can arise within family members as emotions run high and goals differ. The book presents the pros and cons of laws allowing assisted suicide (laws such as Oregon's Death and Dignity Act that was so recently in the news).

At the same time, it presents the choices in some very personal case studies, including the one for the author and his father. The facts address the logic of the situation, and the case studies incorporate the emotions and ground abstract ideas into real life scenarios. Again and again, the book returns to the concept of choice. Choices exists, but the conversations about those choices must take place.

The author writes with the understanding that comes with a medical background and the compassion that comes from facing these choices within his family. This combination makes the book approachable and readable. It leaves with a hope and a goal for medical care:  "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 to expand them, in the name of living a worthwhile life."

I would highly recommend this book to everyone. May these choices be far off for everyone, but at some point, they are coming - whether for yourself or for a family member. Read, learn, and have the tough conversations. I don't think you can ever be prepared, but being informed is a good start.

Please share your thoughts and leave a comment. I would love to "talk" to you.

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