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

Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Doubleday Canada Toronto, 2014. Downloaded as Hachette Digital for Kindle. NF; 12/14.

Dr. Gawande is an American medical-literary superstar and, unlike Verghese and Hadler, for me he avoids the Olympianism characteristic of successful doctor-writers in his country. He writes clearly, and with the content in this book he is close to my own practice area and what he has to say made good sense to me and also taught me something. Not a bad accomplishment for a general surgeon writing way outside his field.

Nobody is perfect. He discusses the possible genetic determination of aging, but argues that that is unlikely because there is no correlation among individuals in families. For me the interesting genetic aspect of aging is the probable general predetermination of lifespan based on the age at which the majority of individuals would have died due to natural consequences like predators and bad weather. No point in developing repair mechanisms that would never have a chance to operate.

Gawande’s story is of his father’s frailty, illness, and death. The young surgeon describes a similar experience to the one I had with my in-laws: he is out of his depth and not only his own medical training and experience but those of both of his parents don’t help much. He goes on a journey at once completely different but also quite similar to Katy Butler‘s. Everybody has to learn the way for themselves.

I was impressed with his first book which was the first one I had run into by a physician (an American, and a surgeon!) where it is suggested that maybe we make mistakes. I was less impressed with the next book which emphasized checklists. You can receive a dose of my attitude to that here.

Two ideas Gawande presents struck me, neither of which I think are original to the author but both well-expressed and new information for me. First, perspective governs priorities. When you are twenty life looks eternal, and you focus on accomplishment. Reaching out into the world and making things happen. When you are 85 life looks short and uncertain, and you focus on your home, your family, and your emotional well-being. But the same shortening of perspective with its different priorities happens when you are 35 and dying of cancer.

Second, how should we figure out what to do with someone, a loved one or a patient, who is near the end of life, losing capability, subject to crisis: frail, in other words? My friend Chip Teel once suggested to me to ask the question, “How do you want to live the rest of your life?”. Gawande adds that we should also ask two other questions: What do you fear the most? and What do you most hope for? I’ve started asking those questions.Then he says:

For a long while I thought that (being unclear which is the wise course of action) 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.

I’m very impressed that this extremely well-trained and highly-regarded practitioner is, on the topic of death, disarmingly humble as he admits in his show and tell that most of the time he doesn’t have any idea what to do. I suspect this would surprise the American public and have the effect of making them listen. And being fearlessly critical of the profession strikes a chord with me:

The doctor did some tests. He found that she had thinning bones and recommended calcium. He fiddled with her medications and gave her some new prescriptions. But the truth was he didn’t know what to do. We were not bringing him a fixable problem… he had no answers or direction or guidance. He could not even describe what to expect would happen.

and:

…the way we deny people (sharing memories, passing on wisdom and keepsakes, settling relationships, establishing their legacies, making peace with God and ensuring that those who are left behind will be okay) out of obtuseness and neglect, is cause for everlasting shame. Over and over, we in medicine inflict deep gouges at the end of people’s lives, and then stand oblivious to the harm done.

Dr Gawande is in this book right on the issue that most preoccupies me in the business of primary care of frailty. How can I avoid the common physician’s mistake of failing to focus on my patients’ real inner needs? He provides a fair bit of practical wisdom on how to answer that question. 8.9/8.3.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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