Medicine and What Matters in the EndBook - 2014
From the critics
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We've created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets — and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan.
Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.
5 Key Questions at the end of Life:
1. What is your understanding of your current health or condition?
2. What are your fears or worries?
3. What are your goals and priorities?
4. Are there any tradeoffs you are willing to make?
5. What would a good day be like?
When I was a child, the lessons my father taught me had been about perseverance: never to accept limitations that stood in my way. As an adult watching him in his final years, I also saw how to come to terms with limits that couldn't simply be wished away. When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that there are times when the cost of pushing exceeds its value. pg 262
In the end, people don't view their life as merely the average of all 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. pg 238
...Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength. pg 232
The choices don't stop, however. Life is choices, and they are relentless. No sooner have you made one choice than another is upon you. pg 215
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. pg 31
People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have 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.
Consider the fact that we care deeply about what happens to the world after we die.If self interest were the primary source of meaning in life, then it wouldn't matter to people if an hour after their death everyone they know were to be wiped from the face of the earth. Yet it matters greatly to most people. We feel that such and occurrence would make life meaningless. pg 126
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In 1945, most Americans died at home. By the 1980s that number was down to 17%. Today it is trending back upwards as more people pursue options that allow them to live out their final days in the comfort of their own homes. Doctor and writer Atul Gawande explores how dying became medicalized in the intervening years, as science offered new innovations for beating back disease in the 20th century. Encompassing both the elderly and the terminally ill, Gawande examines how end of life care falls short of providing patients with the best possible quality of life in their final days, instead focusing on what else can be tried to fix the unfixable, and beat back the inevitable. From nursing homes to cancer wards to assisted living facilities to hospice care, Gawande reveals the shortcomings of the institutions we have created for the dying, and asks how we can be better prepared to face the question of mortality with clear eyes and compassion.
While rather horrific to read there was a lot of valuable information. As you age, or if you get a disastrous disease, your body and mind are eroding to varying degrees. Our medical industry is only designed with prolong life not to ensure quality of life (and this comes from a doctor within the system). You get to decide what treatment you want and don't want (and should base that on the outcomes you want and are realistic - not what the doctor tells you have to do). Ask questions and face the reality of your situation. Some times there is no good outcome. If things are grim don't be hesitant to start Hospice care (it can manage the time you have left ). There are basically 3 types of doctors. Doctor Knows Best will just say here is what is wrong with you and here is how we will treat it. Doctor informative will say here is what is wrong with you and here are 10 options to treat it. The 3rd (and most rare) are the interpretive doctors. They tell you what is wrong with you and then ask what your goals are for you life, and then help you find a plan to meet them. As you age you should know what you want out of life and what is an acceptable life and what is not. Communicate your wishes clearly so that your loved ones are not left guessing as to what to do (this is a heavy burden to put on them). Have the hard conversations early even though it is hard. Nursing homes and assisted living are mostly designed for the children of aging parents (see the first quote I added). While a lot of aged care facilities are like prisons, there are exceptions (though rare). Dr. Gawande asserts that people need a reason to live and some degree of control over their lives. and will have better lives if they feel they do. It can be as simple as a house plant to care for or deciding if they want to eat something that may be bad for them.
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