Being Mortal by Atul Gawande Book Summary

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Being Mortal: Medicine and What Matters in the End

    • Scientific processes have turned the process of aging and dining to medical experiments
  • As of 1945 most deaths happened at home. Now only 17%
    • Historically, elders were respected and taken care of by the family and maintained their roles as head of household
    • Process of aging. Tooth loss. vessels and joints hardening and gaining calcium. Muscle loss. Brain shrinks.
    • 40% have dementia by 85
    • Scientists have discovered that all during a single gene can double the lifespan of certain animals such as worms
  • Up until last hundred years, lifespan was ~30… Death was risk in every age
    • Genetics only describes 3% of lifespan variance. Identical twins die 15% apart
    • There is no singular cellular cause of aging – multiple micro issues
  • One of the biggest risks of the elderly is falling so geriatrician would closely examine feet
    • The key treatment for a geriatrician is quality of life
    • There was a study comparing the results of geriatrics and regular physicians. The geriatrics achieved 20% less depression and 40% less home services even though the death rate was the same
    • The geriatricians focused on simplifying medicine regimes, trimming toenails and good meals
    • Scores of the medical centers across the country have shrunk or closed their geriatric Centers
  • There is no way to train enough geriatricians
    • One proposal is to have current geriatricians train primary care physicians. 97% of doctors do not take a single class in geriatrics
    • 1910  – pour houses. Where old people, drunks, and invalids would go
    • People in the past would balk at us complaining about nursery homes
    • Modern old age homes were more about the children’s comfort and improving the elderly’s lives
    • In the 20th century, hospitals ushered in unprecedented results
    • Eventually, the elderly would go to hospitals for their care
    • In 1954, the hospitals lobbied Congress for nursing homes so that the elderly would not be filling up all their beds
    • The modern era did not make nursing homes to assist the elderly with long-term care, but rather it was a way to help the hospitals
    • Nursing homes are like prisons. Their definition of care is safety. But that is not living.
  • The elderly feel that nursing homes are more like hospitals than homes.
    • Rigid schedules of the institution
  • How do we make life worth living for those who are weak and frail?
    • Independent living, then assisted living, then nursing home
    • Home was the key question. The place needed to feel like home
  • In 1983, Park Place, the first assisted living center opened. It had locks on the door. Private apartments. And gave the elderly the freedom. At the same time, they had 24 hour nursing and assistance with food and daily routines
    • As people get older, they prefer to spend time with family more than friends. The opposite is true if you are younger
    • Older people are happier than younger people
    • Carson, Stanford psychologist, thought this had to do with perspective. Knowledge of your own mortality.
  • How we spend time depends on how much time we think we have
    • When future ahead of you is finite and uncertain, your focus shifts to the here and now, Every day pleasures, and the people closest to you
    • Socio emotional selectivity theory – perspective matters
    • Study on those with aids – chose similar to old
    • The simple service of companionship and and provide everyday comforts is what the elderly need
    • Suddenly, assisted living grew rapidly. Then, people not true to the vision started using that name
  • Harvard doctor (bill Thomas) from upstate New York thought the way to improve nursing homes is to introduce life. Plants, children, and animals
  • Boredom, loneliness, and helplessness are the three plagues of nursing homes
    • People started coming to life with all the animals around
    • Death rates fell. The theory is that the animals gave them a reason to live
  • Medical professionals focus on repair of health. Not sustenance of the soul.
  • The paradox is that we’ve decided that medical professionals should decide how we live in our waning days
    • We’ve decided that aging and mortality is a medical concern
  • Safety and protection is not all that we seek in life
  • Autonomy is being the writer of your own story
    • Bill Thomas decided to start a nursing home from the ground up, the greenhouse
    • Each unit had no more than 12 people staying in them
    • Each caregiver would help them get ready, cook, and administer medicines so that they developed more personal companion relationships
    • As people age it becomes more important to curb our medical judgment
  • In the US, 25% of Medicare spending is in the final year of their life. Often when there is no potential benefit
  • The priorities of people with serious illness include: avoid suffering, strengthen relationship w family and friends, not burdening others, and feeling like life is complete
    • Dying in an icu does not provide any of this
  • Hospice care is where you go if you’re willing to sign a form that says that your condition is terminal
  • The goal of hospice is not to extend the life, but to make your current life comfortable
  • 40% of oncologist give treatment that they know will not work
    • Most doctors overestimate how long patients have to live
    • Health insurance company delayed treatment for one breast cancer patient, and even though the treatment would not have worked, jury awarded family 89m. So now insurance companies will continue to fund end of life treatments.
  • People who had a discussion about their end-of-life care were more likely to die at peace, Live longer, and their family was less likely to become depressed
    • Lacrosse, Wisconsin life expectancy over one year longer. In 1881, lacrosse began open campaign discussing end of life care
    • Do you want breathing tube? Antibiotics? Etc.
    • Discussion had brought lacrosse end of care price down 50%
    • The best process for informing a patient and their family that they are dying is to take your time
    • Sometimes, it is easier for doctors to just prescribe chemotherapy. But then, the last months can be miserable
    • Palliative care professionals three magic words were “I am worried” another set of magic words is “what do you want to know?”
  • Technological society has forgotten the dying roll people want to pass on memories, pass on wisdom, complete their legacy and then sure that those they left behind will be okay

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