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Being Mortal: Medicine and What Matters in the End Paperback – 16 December 2015
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- Print length296 pages
- LanguageEnglish
- PublisherPenguin Books India
- Publication date16 December 2015
- Dimensions19.8 x 12.9 x 1.79 cm
- ISBN-100143425579
- ISBN-13978-0143425571
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About the Author
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- Publisher : Penguin Books India; Latest Edition (16 December 2015)
- Language : English
- Paperback : 296 pages
- ISBN-10 : 0143425579
- ISBN-13 : 978-0143425571
- Item Weight : 210 g
- Dimensions : 19.8 x 12.9 x 1.79 cm
- Country of Origin : India
- Net Quantity : 1.00 count
- Best Sellers Rank: #3,131 in Books (See Top 100 in Books)
- Customer Reviews:
About the author

Atul Gawande is the author of three bestselling books: Complications, a finalist for the National Book Award; Better, selected by Amazon.com as one of the ten best books of 2007; and The Checklist Manifesto. He is also a surgeon at Brigham and Women's Hospital in Boston, a staff writer for The New Yorker since 1998, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won two National Magazine Awards, a MacArthur Fellowship, and been named one of the world's hundred most influential thinkers by Foreign Policy and TIME. In his work as a public health researcher, he is Director of Ariadne Labs a joint center for health system innovation. And he is also co-founder and chairman of Lifebox, a global not-for-profit implementing systems and technologies to reduce surgical deaths globally. He and his wife have three children and live in Newton, Massachusetts.
You can find more at http://www.atulgawande.com.
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Medicine and What matters in the End
“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.” Dr. Atul Gawande in his path breaking book on Geriatrics and Palliative Care says “We have 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.”
In what I consider as a deeply moving book, Gawande stresses on the need for a doctor to accept the reality of mortality and accordingly make it a focal point in the way he treats the dying. In the Introduction he says that he remembers discussing mortality during a seminar, spending more than hour on Leo Tolstoy’s classic ‘The Death of Ivan Ilyich’ (I have discussed this book in one of my earlier posts on ‘A Dignified Exit’). Gawande quotes Tolstoy “What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo treatment and something very good would result.” He says that they as medical students saw it, the failure of those around Ivan Ilyich to offer comfort or to acknowledge what is happening to him, was a failure of character and culture. He admits that within a few years of surgical training and practice, he encountered patients forced to confront the realities of decline and mortality and that it did not take him long to realize how unready he was to help them.
The book is replete with the author’s confrontation with terminally ill patients, the aging and dying. The book traces the slow development of palliative care from Nursing Homes to Hospices to Assisted living.
This book disturbs you. It lays bare the reality of aging and increasing dependence. In the chapter ‘Dependence’ Gawande says “It is not death that the very old tell me they fear. It is what happens short of death – losing their hearing, their memory, their best friends, their way of life.” He says we do not think about the eventuality that most of us will spend significant periods of our lives too reduced and debilitated to live independently. As a result, most of us are unprepared for it.
With the changes in the family structure gravitating towards splinter groups the isolation and dependence of the aged has become acute. Nursing Homes and Hospitals where doctors and nurses more bothered about continuing procedures to check whether there are means of extending life even when they know that the patients has passed beyond such a stage only end up in extending the suffering of the patient.
Gawande, argues that quality of life is the desired goal for patients and families. He talks about more socially fulfilling models for assisting the infirm and dependent elderly. It is in this context that he outlines at various points in the book about hospice care to ensure that a person's last weeks or months may be rich and dignified. Hospice includes palliative care for the incurably ill given in such institutions as hospitals or nursing homes, but also care provided to those who would rather spend their last months and days of life in their own homes. He also describes Assisted Living as another fulfilling way of taking care of people with disabilities.
Referring to a book ‘The Philosophy of Loyalty” written by a Harvard Philosopher Josiah Royce, Gawande says that Royce wanted to understand why simply existing – why being merely housed and fed and safe and alive – seems empty and meaningless to us. What more is it that we need in order to feel that life is worthwhile? The answer he believed is that we all seek a cause beyond ourselves. This was to him, an intrinsic human need. The cause could be large (family, country, principle) or small project or the care of a pet. The important thing was that in ascribing value to the cause and seeing it as worth making sacrifices for, we give meaning to our lives meaning.
The book details about the efforts put in by individuals to find ways and means of improving the quality of life of the old and infirm, a number of them from their own experiences of tending to an aged parent or a spouse.
But the most telling part of the book is Dr.Gawande’s own account of handling the final stages of his father. The ending part of the book where he describes his father’s final days is intense and moving. In the beginning of the book he talks about his grandfather who lived till the age of a hundred and ten years and ultimately passed away surrounded by a large family in the midst of the people he loved and in his home. He says “My father’s father had the kind of traditional old age that from a Western perspective, seems idyllic” He continues “But in my grandfather’s world, how he wanted to live was his choice, and the family’s role was to make it possible”.
Despite having spent the entire part of his life in the US, born and bred up there, his father (a doctor himself) having migrated much earlier, Dr. Gawande comes to immerse the ashes of his father in the Ganges as per his wish –
“It’s hard to raise a good Hindu in small town Ohio, no matter how much my parents tried. I was not much of a believer in the idea of gods controlling people’s fates and did not suppose that anything we were doing was going to offer my father a special place in any afterworld. The Ganges might have been sacred to one of the world’s largest religions, but to me, the doctor, it was more notable as one of the world’s most polluted rivers ------ Yet I was still intensely moved and grateful to have gotten to do my part. For one my father wanted it, and my mother and sister did, too.”
Atul Gawande is a fantastic writer and has your attention till the end. More importantly he has touched on a subject that is the final anxiety of our existence.
Finally the essence is from the film "Anand" - Rajesh Khanna / Hrishikesh Mukherjee - Babu Moshai, Zindagi badi honi chahiye, lambi nahin.
The book opens with an interesting statistic. In USA, till 1945, most deaths occurred at home. By the 1980s just 17% did. The rest died in hospitals. What is the reason behind this rather expensive ending? The answer ironically is the progress made in medical care.
The author gives a scary description of ageing process. Teeth decay is most common. Jaw muscles lose about 40% of their mass and bones of the mandible lose about 20%. Ability to chew therefore declines. While our bones and teeth soften, rest of the body hardens. Blood vessels, joints, muscle and valves of the heart pick up substantial amounts of calcium and turn stiff. Since heart has to exert more to pump blood to these stiffened arteries, we all develop hyper tension. Lung capacity decreases. Even our brain shrinks and actually rattles inside making us vulnerable to cerebral bleeding even with minor head injuries. Eventually death becomes a question of when? Not If.
Doctors are trained to keep patients alive as long as possible. They are never taught how to prepare people to die. They therefore subject you to all kinds of therapies and surgeries and prolong life. Should medical profession rethink its approach? Yes! Medical profession at least in developed countries have realized that longevity should be replaced with making life worth living even if it means shortening it. The author now gives various developments taking place and their shortcomings.
Geriatrics specializes in Medicare for aged. Unfortunately this is not a glamorous branch like plastic surgery. Consequently doctors and institutions specializing in geriatrics are few in number.
What can be a better option than a nursing home for the aged and debilitated? Comfortable bed, nursing care, timely medications, doctor on call and above all not being a burden on the children. On the face of it a nursing home appears ideal and several have come up to suit all budgets. The reality however is different. Old people hate nursing homes. The author explains why? Nursing home is two words. Not one. Besides nursing, it has to be home as well. Prisons, orphanages, mental hospitals and military barracks have striking similarities with nursing homes. It is a regimented life denying adults the much needed autonomy and self respect.
Assisted living is a radical improvement over nursing homes. Inmates enjoy better autonomy. The group living concept helps in overcoming monotony. Management allows inmates to take certain risks. The underlying philosophy is happiness of the inmates rather than keeping them alive at any cost.
Hospice is an institution that takes care of chronically or terminally ill. There are also hospices at home facilities. In USA it is legal to get consent of the inmate to these questions.
Do you want to be rusticated if your heart stops?
Do you want aggressive treatments such as intubation and mechanical ventilation?
Do you want antibiotics?
Do you want tube or intravenous feeding if you can’t eat on your own?
The hospice also assists in framing a will and record last wishes of the patient.
Hospice also provides palliative care to reduce pain and suffering by administering sedatives, pain killers, psychiatric drugs etc. There are approved procedures and WHO guidelines on palliative care.
A modern trend that is gaining support is called physician assisted suicide (PAS). This should not be confused with euthanasia or mercy killing. In PAS the decision to die rests with the patient. The physician merely prescribes a lethal dose of barbiturates and the patient is free to take it whenever he desires. Assisted suicide is legal in the states of Oregon, Vermont and Washington in USA.
The book ends on a philosophical note. Dr Gawande visits Varanasi to immerse ashes of his father in Holy Ganges.
There is a saying in Hindi. “To attain Moksha, one has to die!” let us therefore accept that we are mortals and be happy about that fact.
Being Mortal is good book. I strongly urge you to read it.
Top reviews from other countries

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.

- 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.



Being Mortal's main focus is on how medicine and medical care has maybe skewed our perception on what it means to live. Does the quality of the life we have at the end often get overshadowed by a focus of extending our life -- even if this extension comes at the cost of stripping our final days of everything that gives meaning to a definition of "Life".
The book begins by investigating the kind of care that is offered to our culture's elderly; a care that can, more often than not, remove as much of their autonomy and dignity as possible in favour of safety. The latter half of the book then moves into discussing the kind of medical direction that is adopted with/by those who are diagnosed as terminally ill.
In both cases, Dr Gawande, eruditely and with much sensitivity, proposes that a better kind of end-of-life-care would be given, and a better quality/freedom of life would be had, if we moved our focus away from trying to ward off the inevitable and placed it instead on assisting and cultivating what life there is remaining. Gawande's proposition is for a more considered medical approach towards those facing the final chapter of their story; one that would allow people to maintain as much control of their life as possible. In such cases the question is not a matter of "would we like to live or die", but what quality of life would we like to have available to us prior to the end, and what levels of quality are we prepared to "trade" in order to extend what little time we have left? The concern of medicine and care would therefore be more inclined in providing the patient with an attainable desired life and not putting them through unnecessary cycles of treatments which, inevitably, erode what quality of life could be had whilst giving so little time (if any) back in return. In such an application, the "well-being" (physically, mentally and emotionally) of the patient would be more important than treating the incurable.
In short, could our current medical practice (along with our own expectations of what medicine is for/about) be failing those who are facing death by preventing them from experiencing as much life as is possible in their final moments?
Such an approach does require us courageously accepting our own mortality; which is a modern challenge in the technological age we live in, and something our ancestors never really struggled with. But this acceptance would lead us towards embracing a life we can have now instead of forfeiting this for something that, sadly, lies beyond our reach.
At this point, some may be thinking that Being Mortal is about Euthanasia. Although this highly complex ethical issue is briefly discussed within the book's eighth chapter (entitled Courage), the context of the book is not arguing for prematurely bringing someone's life to close ("assisted dying"), but improving the quality of life for those who are terminal, and helping them to best prepare, both emotionally and physically, for this end. In other words, this book is arguing for "assisted living". That said, I'm certain that both sides of the Euthanasia debate would find much food for thought within Dr Gawande's writing, along with examples that could be taken to both strengthen and challenge their held positions. Personally, I'm not sure whether the topic under discussion within this book would fall under the header of Euthanasia; it could be argued that prolonging treatment to fight a terminal illness that has already won, could lead into an earlier death.
I found this book extremely fascinating, poignant and sobering. I'll admit, at the age of thirty-five, the quality of life I would desire at my own end isn't something I've given much thought to. I have now. Reading this book will certainly have that affect on you. But the book has also made me think a lot about others, especially the elderly I know and love.
Death, and preparing for it, is such a difficult topic to discuss. So I admire Dr Gawande's courage and compassion as he navigates this issue; and he navigates it very well. To help him in this task, many personal stories from those who have faced this natural crisis have been used; even Atul's own moving description of his father's last years. At first, I found some of the core issues raised by these stories repetitive; wondering whether they could have been condensed together. However, with the hindsight that birthed when I was about three quarters of the way through this book, I became very grateful for every syllable. These personal words help to enlarge our perception of what it means to live; they enable us to grasp how universal our hopes and fears are when it comes to preparing for the end of our own tale.
It is -- though it may seem a very awkward thing to read in public -- an excellent book. One that maybe we all should read.
-- Tristan Sherwin, author of *Love: Expressed*