1. Young, Robert C. MD

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Being Mortal, the latest in the steady stream of illuminating books on medical subjects by the remarkable surgeon-author Atul Gawande, addresses the problems of aging and end-of -life care. As someone who is solidly on the right side of life's bell-shaped curve, this reviewer found Being Mortal enlightening, instructive, and humanizing.

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Dr. Gawande begins with the perspective of a young medical student. Medical students come to the field because of their compassion and empathy. What they don't have, though, is the knowledge of how to treat and how to cure illness. Their medical education begins a transformation that shifts the physician's focus to that of treatment and away from the more encompassing concept of aid.

ROBERT C. YOUNG, MD.... - Click to enlarge in new windowROBERT C. YOUNG, MD. REVIEWED BY ROBERT C. YOUNG, MD Chairman,

Before concentrating on the central theme of his book, Gawande explores the human desire for independence. In modern societies, this has resulted in a natural evolution toward the separation of families. As he says, "Global economic development has changed opportunities for the young dramatically. Prosperity depends upon escaping the shackles of family expectation to follow their own path." This is true for both children and parents. Parents want "intimacy at a distance." This has led to an entirely new model of how contemporary families live their lives.


He then throws the aging process into this equation, showing how, for many, the gradual and inevitable deterioration of function dramatically alters this dynamic when the adults in the family can no longer be independent. Unlike Gawande's grandfather, who simply aged at home, continuing his role of family patriarch while being cared for by a large and loving family, modern families face a more complex and harder truth: What do we do with Dad?


Gawande then chronicles the development of care centers for aging patients, taking us through the history of poor houses, hospitals, nursing homes, assisted living facilities, and retirement communities. Finally he describes some of the really novel facilities that actually address the elderly's needs for a life with independence and with meaning.


The examples are both instructive and encouraging. But these contemporary care centers face two major obstacles: Regulations, which place legal constraints on them to insure safety, and the constant intervention from medicine's desire to fix. In Gawande's view, "Medical professionals concentrate on repair of health, not sustenance of the soul."


So what do the elderly actually want in the portion of their life that is physically compromised but when death is not imminent? Gawande says: "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."


In the later two chapters-"Letting Go" and "Hard Conversations"-Gawande comes to grips with the central theme: Because being honest about prognosis is so difficult and emotionally charged, and because doctors don't want to dismantle hope, we continually use terms like "regression" and "response," which are technically correct but don't address the fundamental reality of the illness.


This is unrealistic but understandable. But it is also unfair and unprofessional. In a study in British Medical Journal of 500 terminally ill patients, 63 percent of doctors overestimated survival, and only 17 percent underestimated it. Of note, the better the doctor knew the patient, the more likely the estimate was to be incorrect (Christakis and Lamont: BMJ 2000:320:469-473).


One of His Most Effective & Endearing Qualities...

One of Gawande's most effective and endearing qualities is his use of his own shortcomings to illustrate his points. For example, when caring for a patient with thyroid and lung cancer, a partial response to her thyroid cancer led Gawande to suggest that "perhaps experimental therapy could work against both of her cancers"-which he realized was sheer fantasy. He implores us to be honest with patients and with ourselves about the critical distinction between cure and care.


Once that distinction is made and discussed openly, it allows possibilities for a whole new approach to patient care. One can then integrate hospice and/or palliative care with conventional treatments. He quotes what is now a well-known New England Journal of Medicine study on Stage IV lung cancer patients, where half of them received usual care and the other half had usual care plus parallel visits with a palliative care specialist. Those who saw the palliative care specialist entered hospice earlier, stopped chemotherapy earlier, experienced less suffering, and lived 25 percent longer (Temel et al: NEJM 2010;363:733-742).


Gawande devotes substantial portions of the book to conversations between doctors and patients at the end of life. Here, as he says, words matter. You don't ask, "What do you want at the end of your life?" You ask, "If time is short, what is most important to you?" These are difficult but critical questions that enable doctors to deliver what the patient desires and not just what is possible or convenient.


Patients or family members often want the doctor to continue until there is nothing more that can be done. But rarely is there nothing more that doctors can do. We must resist the desire to try to fix something when a different sort of care is required.


Gawande is a master at using his own personal observations and experiences and, as noted, often his own failures to illustrate important lessons. He writes beautifully but succinctly. He seamlessly couples scientific information with personal illustrations. This book should be required reading for anyone entering the field of Oncology. Absorbing his message will make them a better oncologist and a more satisfied doctor.


Gawande leaves us with this thought: "The simple view is that medicine exists to fight death, and that is, of course its most basic task. Death is the enemy. But the enemy has superior forces. Eventually it wins. And in a war you cannot win, you do not want a general who fights to the point of annihilation. You don't want a Custer. You want a Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can't."




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