Being Mortal: Medicine and What Matters in the End by Atul Gawande
In “Being Mortal”, physician and noted author, Dr. Atul Gawande, tackles the difficult subject of palliative care and end of life. How do “we” as a physician or “we” as a patient and society discuss this topic, so as to improve quality and not just quantity of life? With poignant memories from his experiences as a surgical oncologist at Brigham and Women’s Hospital, and from those he interviewed in the hospice and palliative care field, Dr. Gawande artfully explores the evolution of elder care, and provides insight and advice on how to skillfully initiate and navigate end of life and palliative care discussion.
Society has changed wherein once communities and large families cared for the elderly, now the elderly are cared for by nursing homes and assisted living facilities. Dr. Gawande documents the evolution of the cottage nursing home industry to that of a multibillion-dollar behemoth. Changes in Medicare laws and federal financing of community hospitals in the 1950’s triggered a massive building spree of community hospitals throughout the United States. As these hospitals filled up with elderly patients who did not require acute medical care, the hospitals needed a place to send patients to and hence the rapid growth of the number of nursing and assisted living facilities. As these nursing homes and assisted living facilities grew, they needed to develop a system of scalability for the massive influx of elderly residents while meeting industry regulations. To achieve this growth, patient autonomy was sacrificed for safety, fear of litigation, and the scheduling of staff for these facilities. Dr. Gawande explores new models of elder care that reinforce autonomy, including nursing homes that allow for pets to live with the residents and daily schedules personalized for the resident.
Throughout the book, Dr. Gawande stresses the importance of physician patient communication. Using language is equally as important as using a scalpel or a medical instrument well. Picking the right words to say and when to say it, creates the tone for the difficult discussion on how far to proceed with medical treatments. In the book, Dr. Gawande insists on using phrases such as “I wish, I hope, and I worry” to empathize with the patient, to prevent alienation and hostility from patient and family, and to instill humanism in medicine. He takes time to listen to their stories since stories can better clarify the patient priorities. Understanding their priorities allow physicians to help interpret and guide the patient decision-making process.
In one memorable example, Dr. Gawande has a patient with metastatic cancer causing intestinal obstruction. He asked her what her biggest fears and goals are, and which tradeoffs she was willing to make. With this information, Dr. Gawande was able to help her interpret the risks, complications, and benefits in framework of her fears and short term goals. Intraoperatively, he made a decision not to pursue a risky diverting ileostomy knowing that she was not willing to risk the possibility of intestinal perforations, and he decided to abort a risky surgery in favor of peritoneal drains to release the intrabdominal pressure.
However, the increase time pressure to see more patients, and to perform more procedures make it difficult for physicians to hold important goals of care conversations with their patients. In the book, Dr. Gawande advocates for all physicians to be proactive in discussing end of life care and advance directives with their patients while they are still able to make decisions on their own. For those not in geriatrics or palliative medicine, these conversations do not come naturally and many practicing and newly minted physicians have not received any formal medical or resident education on the art of communication especially in the palliative care setting.
At the end of the book, Dr. Gawande is faced with the difficult responsibility for caring for his father, also a surgeon, who was diagnosed with a terminal central nervous system tumor. In this situation, he finds himself in the role as son and patient advocate and not as the treating physician. Dr. Gawande learns to apply the earlier principles and advice he discussed in his book. He speaks frankly with his father and asks him what his wishes are and the risks he is and is not willing to take. This relieves the family of making difficult medical decisions when the goals have been clearly stated to the family by their loved one. Additionally, he shared his father’s experiences with hospice. He recounts how the nurse practitioner was able to manage his father’s pain medications in a systematic fashion, so that he was able to walk around the home, work on his charity, and talk to his grandchildren.
Overall, the book is well-written in a story-telling narrative and does an excellent job exploring the complicated topic of aging and death, and examining the patient-physician relationship at the end of life. As someone who also had a father pass away from cancer, Dr. Gawande’s memoirs of his father’s journey strikes a chord with me. Having participated in many family meetings with my father, I can better appreciate when doctors personally address the needs and interests of a patient in goals of care meetings. Fortunately, for those who have not had many experiences with such meetings, this book is an excellent start to learning the art of communicating and counseling patients and their families in their time of need.
Acknowledgements
Disclosure: The author declares no conflict of interest.
