Being Mortal: Medicine and What Matters in the End

Nursing Book Club

Being Mortal: Medicine and What Matters in the End

What nurses should know about end-of-life issues

By Atul Gawande (Metropolitan Books, 2014)
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Reviewed By Christine Contillo, RN, BSN

In his new book, Being Mortal, Harvard professor and practicing surgeon Atul Gawande, M.D., MPH, explores the expanding limits of modern medicine and our ability, both as family members and as clinicians, to help others prepare for the inevitable decline that comes with advanced age.

Withering on the Vine

Gawande opens his book by comparing the maladies of old age to a vine — one that grows so slowly that its changes are imperceptible, but nonetheless inescapable. He observes that medical science has given us “remarkable power” to test the boundaries of biological limits. The problem arises when “we fail to acknowledge that such power is finite and always will be.”

He describes both the lifestyle options open to us and the risks to our health as we age. While we fear heart disease and cancer, some of the biggest risks to the elderly are falls due to lack of balance and the use of multiple medications.

Forty percent of elderly patients who fall will spend the next year in a nursing home and 20 percent will never walk again. If that happens, living alone may no longer be possible, but families may live too far away or be unable to help with the custodial and technological duties of care.

Poorhouses for indigent seniors with no savings have given way to nursing homes and an assortment of senior communities, assisted living and even memory care units. But which is needed, which is best and which is affordable? And who will pay for it?

Searching for Meaning

While advancements in medical science have made it possible for us to live longer and better, Gawande says the medical world has been largely unprepared for the variety of choices now available. In days past, medical providers simply made the choices for their patients. Now, families and patients have many options and want the risks and potential outcomes explained in a way that is meaningful.

Particularly tricky is helping families decide how to proceed in a case of terminal illness. Quoting palliative care expert Susan D. Block, M.D., Gawande notes that family meetings about diagnosis need to help the patient negotiate anxiety. These meetings take time and plenty of it. The patient needs to be heard and the language used is very important.

Gawande readily admits that many physicians are far more skilled at presenting information than at drawing out the patient’s grasp of the meaning. Families today have access to huge amounts of information on the Internet; doctors need to explore fears, goals and what the patient considers acceptable trade-offs.

A central question is what the patient really wants. Even in lifelong patient-doctor relationships, the answer may be far afield from what you might expect. With a finite amount of time left, guessing is just not good enough.

Facing the Inevitable

Being Mortal is a profound study of the choices to be made in the final decades of life. Long after I finished reading, I realized how greatly this book had gently nudged my perspective. Certainly, we all try our best to stave off death — whether through better diet, exercise, medication, procedures or testing — but Gawande helps us face the inevitable in a way that’s much more helpful than grim.

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