Review: Being Mortal: Medicine and What Matters in the End by Atul Gawande

5 stars for Being Mortal: Medicine and What Matters in the End by Atul Gawande.

Deciding on the book to kick-start Year 2018 with is tricky business. In the past, I will never have given much thoughts to this first book. However, my way of thinking starts to change since 2015, when by chance, I started that year with The Walk series by author Richard Paul Evans. Somehow or other, the story brought me hope, faith and a sense of peace and helped to set my reading mood for that year.

This New Year, I ask myself "what kind of mood and tone am I looking at to set my reading in the coming days, weeks and months?". I look at my reading list many times before I realise that the answer has been staring me right in the face all the while. I have decided. It is time to confront mortality (via reading), the condition of being mortal.

Being Mortal: Medicine and What Matters in the End.

This is a book about the modern experience of mortality — what it is like to live, grow old, fall sick and die, and how medicine has changed the experience and how it has not.

The author, a surgeon, writer, and public health researcher, stresses time and again, the importance of managing end-of-life issues with patients and their families. By trying not to think about the final phase of the human life cycle, oft-times people end up with institutions (hospitals, assisted living facilities, nursing homes) that address any number of societal goals — from taking burdens off families’ hands to coping with poverty among the elderly — but never the goal that matters to the people who reside in them: how to make life worth living when they are weak and frail and cannot fend for themselves anymore.

There are invaluable lessons to be learnt from this book about aging, attitude to death, quality of life, consequences of sacrificing time now for time later instead of living for the best possible day today, and terminal care. These lessons are of vital importance because people die only once and there is no prior experience to draw on.

The foremost question in my mind now is "Will I have an ending whereby I am able to make the choices that meant the most to me?"

This, in turn, brings me to the four questions of paramount importance that I have learnt from Dr. Gawande; questions that, I will in all likelihood have to ask myself and provide the answers some day.

(1) What is my understanding of the situation and its potential outcomes?

(2) What are my biggest fears and concerns?

(3) What are the trade-offs (sacrifices I am willing to endure now for the possibility of more time later) I am willing to make and not willing to make?

(4) What is the course of action that best serves this understanding?

Indeed, I have chosen a heavy topic to read. Medicine and what truly matters in the end certainly provides food for thought. What makes life worth living when we are old and frail and unable to care for ourselves? Do we get to live the way we wish and with our families around us right to the end?

Being Mortal is a book for everyone; a must-read for all. Eventually, death will come knocking on our doors one day and we need to prepare ourselves for the inevitable to happen. Even then, for all our preparations and whatever we think we have learnt, we may not be ready for it when that day arrives. If you have yet to seriously think about what matters in the end, this is an excellent book to get you started.

Last but not least, I like to say that there are so many well written and meaningful passages in this book that I find myself reading and rereading them before moving onto the next section. Initially, I have wanted to quote only a few lines out of the whole passage but I find that once truncated, the intended meaning and impact is lost. So, I have taken verbatim from the whole passage, rearrange into shorter paragraphs for easy reading, and list them under notable passage 1, 2, 3, and so forth.


Publisher: Picador; Reprint edition
Publication date: 5 Sep 2017

*** Notable passage 1 ***

Even our brains shrink: at the age of thirty, the brain is a three-pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room. That’s why elderly people like my grandfather are so much more prone to cerebral bleeding after a blow to the head — the brain actually rattles around inside.

The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized. As a consequence, memory and the ability to gather and weigh multiple ideas — to multitask — peaks in midlife and then gradually declines.

Processing speeds start decreasing well before age forty (which may be why mathematicians and physicists commonly do their best work in their youth). By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia.

*** Notable passage 2 ***

..how we seek to spend our time may depend on how much time we perceive ourselves to have.

When you are young and healthy, you believe you will live forever. You do not worry about losing any of your capabilities. People tell you “the world is your oyster,” “the sky is the limit,” and so on. And you are willing to delay gratification — to invest years, for example, in gaining skills and resources for a brighter future. You seek to plug into bigger streams of knowledge and information. You widen your networks of friends and connections, instead of hanging out with your mother.

When horizons are measured in decades, which might as well be infinity to human beings, you most desire all that stuff at the top of Maslow’s pyramid — achievement, creativity, and other attributes of “self-actualization.”

But as your horizons contract — when you see the future ahead of you as finite and uncertain — your focus shifts to the here and now, to everyday pleasures and the people closest to you.

*** Notable passage 3 ***

The terror of sickness and old age is not merely the terror of the losses one is forced to endure but also the terror of the isolation.

As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world — to make choices and sustain connections to others according to their own priorities.

*** Notable passage 4 ***

Like many other people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain.

But multiple studies find otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or end-stage congestive heart failure. For the patients with breast cancer, prostate cancer, or colon cancer, the researchers found no difference in survival time between those who went into hospice and those who didn’t.

And curiously, for some conditions, hospice care seemed to extend survival. Those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.

The lesson seems almost Zen: you live longer only when you stop trying to live longer.

*** Notable passage 5 ***

At least two kinds of courage are required in aging and sickness.

The first is the courage to confront the reality of mortality — the courage to seek out the truth of what is to be feared and what is to be hoped. Such courage is difficult enough. We have many reasons to shrink from it.

But even more daunting is the second kind of courage — the courage to act on the truth we find. The problem is that the wise course is so frequently unclear.

For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that.

One has to decide whether one’s fears or one’s hopes are what should matter most.

*** Notable passage 6 ***

In the end, people don’t view their life as merely the average of all of its moments — which, after all, is mostly nothing much plus some sleep.

For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens.

Measurements of people’s minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life may be empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.

Unlike your experiencing self — which is absorbed in the moment — your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out.

Why would a football fan let a few flubbed minutes at the end of the game ruin three hours of bliss? Because a football game is a story. And in stories, endings matter.

*** Notable passage 7 ***

A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.

*** Notable passage 8 ***

Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone.

Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.

We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way.

~ Being Mortal: Medicine and What Matters in the End
Atul Gawande

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From Atul Gawande, a book that has the potential to change medicine – and lives.

Medicine has triumphed in modern times, transforming the dangers of childbirth, injury, and disease from harrowing to manageable. But when it comes to the inescapable realities of aging and death, what medicine can do often runs counter to what it should.

Through eye-opening research and gripping stories of his own patients and family, Gawande reveals the suffering this dynamic has produced. Nursing homes, devoted above all to safety, battle with residents over the food they are allowed to eat and the choices they are allowed to make. Doctors, uncomfortable discussing patients’ anxieties about death, fall back on false hopes and treatments that are actually shortening lives instead of improving them. And families go along with all of it.

In his bestselling books, Atul Gawande, a practicing surgeon, has fearlessly revealed the struggles of his profession. Now he examines its ultimate limitations and failures – in his own practices as well as others’ – as life draws to a close. And he discovers how we can do better. He follows a hospice nurse on her rounds, a geriatrician in his clinic, and reformers turning nursing homes upside down. He finds people who show us how to have the hard conversations and how to ensure we never sacrifice what people really care about.

Riveting, honest, and humane, Being Mortal shows that the ultimate goal is not a good death but a good life – all the way to the very end.

*Blurb from author's website*

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