Being Mortal: Medicine and What Matters in the End by Atul Gawande (EPUB)

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#1 New York Times BestsellerIn Being Mortal, bestselling author Atul Gawande tackles the hardest challenge of his profession: how medicine can not only improve life but also the process of its endingMedicine 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.Full of eye-opening research and riveting storytelling, Being Mortal asserts that medicine can comfort and enhance our experience even to the end, providing not only a good life but also a good end.

User’s Reviews

Reviews from Amazon users which were colected at the time this book was published on the website:

⭐Doctor & public intellectual Atul Gawande’s 2014 book Being Mortal: Medicine and What Matters in the End basically deserves all the praise it receives. Although it is more about modern aging then about death per se, it certainly fit my mood at the moment. My father, a brain cancer patient in his mid-60s, has been given a push along on this path, so it was still helpful to me to think about aging and decline more generally (significant decline prior to death will happen even in most best-case scenarios — and anyways you can’t know in advance if it really won’t).Being Mortal essentially provides a long, thoughtful, multi-faceted, historically-grounded complaint about the medicalization of aging and death, from someone who really knows and cares. Older adults may become less capable of caring for themselves in various ways, but for the most part they still want the things they always wanted: autonomy in their schedules and surroundings, community, privacy, a specific and concrete reason to get up in the morning. It’s a hell of a demand, to ask people to adjust to completely new surroundings and routines when they’ve never been older and/or sicker.Institutions like hospitals and nursing homes are sort of good at providing some things (specific instances of treatment) and terrible at providing others (emotional warmth, exceptions to the rules, etc). The “assisted living” concept has an interesting history (read it in the book!). Unfortunately, by now assisted living has become a watered-down way station between hospital and nursing home, rather than remaining a bastion of alternative values in elder care as originally conceived.Indeed, the logic of institutions is largely inexorable. If providing meaning (or a lifestyle ripe for it) cannot be measured and incentivized, it will not be reliably or scalably produced.Admittedly, Being Mortal raises more questions than it provides answers. Everyone loves a good news story about kindergarteners who visit nursing homes. But are they changing diapers? Is there really any feasible model for caring for a rapidly aging population other than institutions? And how are you supposed to reward institutions for preserving meaning (an inherently individual task) even while they do the things that institutions are meant to do – get a lot of services provided quickly/reliably in a standardized fashion?No individual person can change the system anyways, but it does seem that (even within the system we’ve got) people are making some crap decisions. Ok, so people are valuing the wrong things – namely, safety over autonomy and the “lottery ticket” of survival/recovery over a better death, sooner. You’re someone who wants to value the right things. So what do you do?You have to do your own research and ask doctors hard questions, because they don’t really like facing imminent death either. You have to broaden your imagination about what acceptable living arrangements for an older person might look like.For instance, maybe you have to accept that your loved one might not get medicine exactly on time or the diet just as the doctor prescribed, because he’s going to sleep in his own bed and raid his own fridge instead. But maybe people don’t want to do those things. Then what?That brings us to my main quibble with Being Mortal: Gawande waffles a bit between what people do value and what they should value. It’s so tempting to talk a big game about what “matters.” But if something really matters, why don’t people choose it? Don’t lots of different things matter? And how could it ever be anything less than very difficult to switch from life mode (focus on safety and the long-term) to end-of-life mode?Perhaps Gawande ought to have sought out some different examples of these values in action. It’s not too hard to imagine a terminal patient forgoing last-ditch treatment, even if it’s not what we’d choose ourselves. It’s much more difficult to imagine a role model of, for instance, an adult child allowing her parent to live in what are widely considered to be “unsafe” living conditions specifically for the sake of that parent’s broader well-being.I want to see examples of real “free-range” senescence. I’d like to read the account of someone who got a call from the police, who found mom passed out in the yard, or even whose parent died in an accidental house fire or something.Many worst-case scenarios (of elders living unaided) will not come to pass, but some certainly will. Then what? Does that change people’s minds, one way or the other? Like trendy “free-range parenting,” it’s probably just much easier said than done. Does that mean a value is going unrealized, or that the person doesn’t hold it in the first place?Maybe many patients don’t even know what they value the most. That’s fair, and part of what palliative care can help them to define, as it becomes increasingly relevant. But maybe there’s nothing satisfying to uncover. There’s no rule that everyone must necessarily value different components of life in a stable fashion. Some people will have very consistent desires, but others will vacillate (especially as they experience the stages of progressing towards death). If you draw a patient’s attention to the dangers of her living independently, she shudders. But when you tell a sad story about a nursing home, she cringes. Maybe she fights with her adult children about where she should go. Maybe she can’t afford her first choice. But that’s simple interpersonal conflict and lack of resources, not unique to old age.You can’t live both independently and in a nursing home. Something’s got to give, and that totally sucks. Some values will be pursued better, and some values will be pursued worse, and some kind of balance must be reached. Care institutions put a finger on the scale, but they didn’t create the problem.The personal economy of value pursuit is simply tricky, from the day we’re born until the day we die. Gawande knows that there are costs associated to the “old” way of dying – it tends to create autonomy for elders at the expense of the younger generation, especially women sandwiched between their children and parents. Many children (and parents) aren’t happy with this anymore, for a variety of reasons, so they face new sets of options (i.e. tradeoffs). Having access to medicine is a double-edged sword, and like many historically-novel conditions humans aren’t inherently well-equipped to deal with it. There’s no technocratic solution to that. If “dying as we lived” is some kind of standard for how we should go, then maybe alone and medicalized makes some sense right now after all.I don’t really have any caveats in recommending this one, though. Just read it (and then try to forget Gawande’s description of how aging bodies feel in a surgeon’s hands as quickly as possible).Book #3 for read about death dot com

⭐Apparently, I’m a slow learner.You would think that when your daughter-in-law encourages you to read a book—you would read it. Ditto book recommendations from your wife.Melinda and Joanne—sorry it took me a year to read this. But thank you. Because “Being Mortal” is now on my Top-10 book list for 2018.In this riveting book, Dr. Atul Gawande reminds us: “People die only once.” So when facing fork-in-the-road sick and dying decisions, “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 warehouse oblivion that few really want.”“Being Mortal: Medicine and What Matters in the End” changed—totally changed—my thoughts about end-of-life decisions. Whew. On one level, I agree that this New York Times bestseller (7,000 reviews on Amazon!) is a brilliant and deep look at the “…still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.” Yet on another surprising level, this writer (four bestsellers), surgeon, and public health leader—delivers fresh management and leadership insights in every chapter.CUSTER OR ROBERT E. LEE? The author says that medicine’s job is to fight death and disease—the enemy—but that the enemy eventually 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.”Yet Gawande admits, “More 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.’ All-out treatment, we tell the incurably ill, is a train you can get off at any time—just say when. But for most patients and their families we are asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve.”What should families do? My suggestion: ask your doctor (like I did this week) if he or she has read “Being Mortal.” (He had.) Gawande notes that medical school taught him two styles of doctor/patient interactions: paternalistic and informative.The “paternalistic relationship” is the “priestly, doctor-knows-best model, and although often denounced it remains a common mode, especially with vulnerable patients—the frail, the poor, the elderly, and anyone else who tends to do what they’re told.”Doctors make the critical choices. “If there were a red pill and a blue pill, we would tell you, ‘Take the red pill. It will be good for you.’ We might tell you about the blue pill; but then again, we might not.”The “informative relationship” sounds good, at first. “’Here’s what the red pill does, and here’s what the blue pill does,’ we would say, ‘Which one do you want?’ It’s a retail relationship. The doctor is the technical expert. The patient is the consumer.”The down side? Doctors become “ever more specialized” and “We know less and less about our patients but more and more about our science.” He writes, “In truth, neither type is quite what people desire. We want information and control, but we also want guidance.” In his medical school, there was also the brief mention of a third type of doctor-patient relationship often labeled “interpretive.”“Here the doctor’s role is to help patients determine what they want. Interpretive doctors ask, ‘What is most important to you? What are your worries?’ Then, when they know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities.”Makes sense right? Gawande notes that this relationship is also called “shared decision making” and added, “It seemed to us medical students a nice way to work with patients as physicians. But it seemed almost entirely theoretical. Certainly, to the larger medical community, the idea that most doctors would play this kind of role for patients seemed far-fetched at the time. (Surgeons? ‘Interpretive?’ Ha!)”But two decades later, the author describes a meeting with his father (also a surgeon) and his father’s neurosurgeon. The task: review the MRI images of his father’s giant and deadly tumor. The neurosurgeon “saw himself as neither the commander nor a mere technician in the battle but instead as a kind of counselor and contractor on my father’s behalf. It was exactly what my father needed.”To get the conversation going in your family, maybe insert a reminder into your Thanksgiving prayer next Thursday that everyone around the table will die only once! Then, mention this book as required reading for at least one family member. (“Grammy—please pass the turkey and that Being Mortal book.”)Dr. Gawande is an amazing writer. The poignant stories are page-turners. The innovative solutions—inspiring and encouraging. I’ve already re-told many of the memorable fork-in-the-road stories (tears will flow) to friends and colleagues and ordered the book for several friends. Be sure to read the hilarious story of the very creative nursing home that added two dogs, four cats, and 100 parakeets! (Memo to Purchasing: Next time, order the cages before the birds are delivered!)I should have jumped on this 2014 book much, much sooner—because I still rave about Gawande’s 2010 insightful bestseller, “The Checklist Manifesto: How to Get Things Right.”I had no idea that there were checklist connoisseurs! “The Checklist Manifesto” moves eloquently through medicine, aeronautics, and sky-scraper construction—noting why checklists will make or break a venture. For example, Boeing’s checklist expert uses “pause points” when designing checklists for pilots in crisis. Within each pause point, he limits the checklist to between five and nine items.As a staff writer for the New Yorker, Gawande’s latest article, “Why Doctors Hate Their Computers,” was published on Nov. 12, 2018. You can read or listen to the article online. (Customer Bucket Pop Quiz: Are computer systems for the doctors or for the patients?)And—get this—Gawande is also CEO of the health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase to deliver better outcomes, satisfaction, and cost efficiency in care. Stay tuned!

⭐It is amazing the impact a difficult conversation can have on the patient and their family. When my mom was faced with death after a decades long battle with M.S. most of which was spent in the continuing care ward of the hospital over two decades ago. my father didn’t know how to handle things. By the time the doctor had asked my dad what my mom would want, she was no longer able to communicate. As a family along with the doctor, we decided that the next time she was in crisis we would not treat her, and let her go. Her end came we she contracted yet another catheter associated urinary tract infection (CAUTI) in the hospital. She died of sepsis May, 20, 1999.Fast forward to 2018 when my father-in-law, an otherwise healthy male in his mid-60s, started developing weakness in his hand which rapidly spread throughout his arm. As we would soon find out, it was amyotrophic lateral sclerosis (ALS). My father-in-law was always a proud man, played college football, served in the Navy, family man, and lawyer who helped many. For him, he did not want to take drugs or live anywhere besides his own home. My mother-in-law and niece tended to his every needs, even when they were exhausted. Near the end, later that same year, help came in the form of hospice. Other than the occasional trip to the ER, he was able to live out his final months as he wished, which has brought some peace to the family.While I was just a kid when my mom was sick and not having any worldly knowledge on living, death and dying, I know that for my own life and for those around me, understanding where to draw the line in the sand is more important that just simply surviving. This book does a great job helping to understand the role of hospice and how to have hard conversations with those that are facing terminal illness or even old age.

⭐I thought I once picked up this book and it contained the quote by Bette Davis saying ‘old age ain’t for sissies’ which I loved. I also thought it contained another quote about who wants to live to 99 with a whole range of health problems that might include poor eyesight and hearing loss, on a dialysis machine and taking every medicine under the sun just to keep breathing – answer; the person with all this who is aged 98. However, neither of these are in this book so I thought I would add them to this review. I love both those quotes and would love to know what book I did actually read these quotes from.- In this book the author, Atul Gwande (a man someone should make a saint) has written a book about death that is full of hope. He looks at how we can better manage and have a good death. Previously most of us died at home but now the majority of us die in hospitals attached to drips and adding to the prolonged memory of end-of-life care.- Man has spent most of the 200 – 300,000 years of existence on this planet, with an average life expectancy of living to the ages of 30 or 40. It is only in the last century that we start to live in longer lives and move from living to an average age of 30 or 40 to an average age of 70 or 80, and our bodies have to adjust the fact that we are ageing and this is not necessarily a natural course of events but we are kept alive for these long periods of time for many people through medicines and healthcare and understanding how we can do this. However, do we really want to then end our final few years separated from loved ones, living in an institution and buried by a mass of tubes keeping us barely conscious.- This book is a fascinating look at how we view ageing and how we might wish to end our days or those of a loved one. Ending up in an institutions such as nursing homes have been likened to a similar institutionalisation that you would resemble prisons or mental facility for people with mental health problems, it’s not dignified, it’s often neglect where old people lose all the sense of dignity that they may have had whilst being independently living on their own, and be given nightdresses and institutionalised clothes with wardens going around making sure you behave in a certain way and do the right thing and end up being treated like a child or someone beneath them. Just because you’re in an institution where you are cared for and there is a lot of care going on doesn’t mean that they can make you fit in with scheduled events and where everything is regimented once they have your money.- However if the alternative is to put the black the burden on a family member such as a daughter who is usually in often is, then they are now the carer and provided medicine, providing meals, and having to deal with people alongside their house rules. So the emphasis of care provided by a carer can be equally bleak and difficult on both parties such as the family member and the older person who requires care.- So if we don’t like institutions and we feel we can’t put the burden of care on family members, what is the solution? Another idea suggested is assisted living where people have their own houses and their own privacy, dignity and ability to control but also have the opportunity to meet other people, and have basic care when provided and necessary. Old people aren’t called patients but are known as tenants and in this setting might be a better alternative. Even when people are old and frail and possibly losing memory and some faculties, we still need to ask the question: what is it that makes life live it worth living and what is a good life even when we might have other areas of concern and be old and frail.- Rachel Carson was somebody who looked at Maslow’s motivation of needs approach and noted that actually it was how perspectives can change for older people because they have a different perspective on life than younger people do. When young, you feel they’re going to live forever and you’re motivated by work goals and making a career. But as you age, your perspectives change – many people get less depressed and feel the more important things are close relationships with families and friends. Your days are limited, you become aware of the fact, your perspective on what’s important changes. In fact, how we perceive everything can help us lead better lives.- However many of the institutionalised independent living places really turned into more like institutions. For what is a better life after all many of these frail people suffer from the three plagues of boredom, loneliness and frailty so could we turn places such as nursing homes into something that tries to manage boredom, loneliness and helplessness? The author also looks at life and what it means that we have to care and be connected to one another and we’ll see what will happen to people even after we die. There are very few people that would ever want to imagine that when they die, an hour later everyone else would be wiped off the planet earth, we care what will happen to people after we’ve gone and for some, dying is the gift that they can help those left behind feel better about the death of a parent or loved one.- The book then switches to a young mother who is giving birth to a baby but through that operation they discover that she has lung cancer and it is terminal. She is a non-smoker (note: 50% of people who have lung cancer are non-smokers). She was then given several courses of treatment and to which she will still probably live no more than a year. The question is what kind of care do we want to give to people who are in the final year of life as 25% of all Medicare in America is spent on people who will have one year left of life and the majority of that money will be spent on the last two months of care before the person dies. Often when people are in the final years or stages of an incurable disease the questions we should be asking are what would they want from this life at this time and what is important. The answers are often creating understanding or close relationships with the people in their lives, filling their lives with some meaning and closure and it’s not necessarily about keeping them alive pumped full of drugs, in and out of consciousness in a hospital bed, sent via tubes and barely registering what’s going on. However, we don’t ask these questions and we should think, is this how I really want to spend my final weeks or days in this way.- End-of-life care in terminally ill patients who particularly might have less than a year to live, are often under the management of doctors who continuously try to find something that might extend life by a few months rather than the years they expect. Many patients think further treatments might extend and offer them an extra 20 years of life when in actual fact almost all statistical evidence says that it might give them all three months. When patients are then given palliative care from trained nurses who without the need to stop curative care they can often form better decisions because people start asking them what is important in their life and help them to understand the realities of what is going to occur. Fascinating stuff that we should think about. In many societies where palliative care is the norm rather than further courses of treatment – particularly in countries that don’t have access to the medicines available in America – life expectancy is often longer than those on relentless courses of expensive treatments. It reminds me of a joke in regards to why they stick steel nails into coffins of people who have died of cancer, it’s to stop the oncologist coming up with one further bout of treatment. After reading the account of one young lady’s decision-making and the whole family’s inability to accept what was going on, her life’s end of life care was just one about an excessive set of treatments without necessarily looking at what is the best way to die. These are questions we need to be asking ourselves. And palliative care nurses could be the best people to do this.- What is also interesting is the end of life care in regards to hospice treatment actually seems to have longer life expectancy than the care that has just given through medical intervention, not by years and only weeks or months, but also it may lead to a better death- If we have to face bad news we also have to think about what we want. Do you want the doctor to inform us about the best medical decisions we can make or do we want the doctor to listen to our fears and try to manage that and address those fears. Hope that a better way would be to give us information and guidance but also try to help us make the decisions that we need to do so even a model of that is listening to the patient, giving advice but tempering that advice with what our fears and needs actually are within relation to possible surgery or further treatment. And I guess it’s important to remember that lots of medical practitioners just want to try and fix a problem and those conversations are hard.- Though Gawande tells many stories in this book – he also talks of his own experiences and of his own family (particularly his dad and grandad). It really helps to crystalise the message that he is telling with this book.- I love the author’s approach by starting with three words when you want to relate and discuss something that might be hard to tackle, and those words are “I am worried”.- The most amazing thing about this book that is about death is that it’s also about a better life to gain some insight and solutions to how we can die – and as Jim Morrison once sang “no one here gets out alive” so it’s worth asking these questions now rather than waiting until it’s too late. A recommended book on death that tells us a lot about how to live.

⭐This book had been chosen as my latest book club choice because we all decided that it would challenge us. There is no doubt of that as we all contemplate the concept of mortality – of peers, parents and our own. All of the group have parents who are elderly, dying or already dead which present constant dilemmas for those left to care or take responsibility in any way.The book is just over 280 pages, split into eight chapters by subject.I was slightly scared to read this book as I expected it to force me to confront emotions that I usually bury. And it’s true that there were some very familiar issues dealt with regarding the quality of life and the moralities of the healthcare system forcing people to live longer than they actually should be able to.The narrative is very easy to read . It is direct, not avoiding difficult subjects and discussing decline/death in the way that you would hope of a physician.It should be noted that this is a US author so the statistics and examples are all from the US. The easiest way to approach this from the UK is assume that everything is the same here but, of course, that isn’t necessarily true.Many problems are raised with the system but, unsurprisingly, not too many solutions are discussed. It is never going to solve problems but will provoke thought which I think is its main purpose. The ideas that are raised are very plausible though and worthy of trying out.There are many points in the book where the author theorises and I thought that it was much more effective when he used real examples to illustrate what he is trying to say.He tackles geriatric care very openly but when he moves on to the mortality of terminally ill younger people the book becomes more controversial – money is always a limiting factor and we are asked to think about whether extending a life temporarily (and miserably) is sensible – he actually refers to this option being the “default choice” of many people in the medical world.

⭐I first got interested in death and in the process of dying in year 2000, after my Mum’s death. Her illness and death went – somehow – all wrong. In this book Atul Gawande explains what can go wrong, and why. My Mum got it all and more. We, the family, were neither prepared nor able to find for her (and for ourselves) a better way to get to the end. If you put in the picture that in Italy – maybe “the” Catholic Country of all – physical pain has always been regarded as the sacred way to get to heaven, (a mentality that is still lingering here and there) – then you can imagine what she went through. Since those days I have red endless books on death and dying: this is undoubtedly one of the best. What people do not understand is that books on these subject are deep, rich, intense and help you to live a better life. If we only could talk freely about death and dying, our life would be richer and happier.

⭐I enjoyed this book more than any other I have read for a long, long time. It was recommended to me by my daughter’s radiographer at Sick Kids Hospital in Edinburgh. I have no medical knowledge but the whole book is so brilliantly written for both medics and laymen. Funny, tragic, fascinating and wholly accurate. I cannot over-emphasise the importance of this book. It gave me so much food for thought. I laughed and cried and highlighted parts franctically throughout. I hope this book will start many new discussions within medical professionals and families alike. Each life ‘story’ in the book is crucial to the bigger picture. I will read this book again to ensure I didn’t miss anything. Thank you for writing such a succinct, self-effacing, encouraging, depressing, and informative read. And thanks to your friends, family and patients for sharing their stories.

⭐A book that rids itself of the schackles of taboo and instead moves boldy yet resspectfully into a profoundly necesssary conversation about death and what really makes living worth it. I read this book from a hospital bed, and one of the bigguest questions Atul tackles is the view that medicine is (ostensibly) provided for our own well being. But to prolong a life and sacrafice well being is a faustian bargain and modern nightmare. He brings to the surface questions we should be asking ourselves, and our loved ones I recommend this book to anyone. To discuss our mortality important. None of us live for ever and at the very least this book has served to lay a foundation within my mind as to what is important to me, what things I trly value most and what to think about when my time or that of the people I love arrives.Ignorance is not bliss and although I don’t expect those moments to be any less difficult If I had read this book after the passing of a loved one and realised I had fallen into the many pitfalls exposed it would have been extremely difficult. I think that if you have anyone close to you that is aging or dealing with serious medical conditions read this book now. Tonight.It wasn’t always easy to get through it, but I’m thankful that I did.

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