Being Mortal (new book)

[Midpack]

Having watched an interview with this author about this book, and having seen/read him before, I suspect this book will be a worthwhile read for those who want a thoughtful follow up to the "Hope to Die at 75" discussion. As much as many people want to bury their heads in the sand ('I want to live as long as possible no matter what') on end of life quality and cost, IMO we'd be better for having thought about it sooner. IMO we owe it to our loved ones, and ourselves.

Being Mortal | Atul Gawande

Medicine has triumphed in modern times, transforming the dangers of childbirth, injury, and disease from harrowing to manageable. But when it comes to the inescapable realities of aging and death, what medicine can do often runs counter to what it should.

Through eye-opening research and gripping stories of his own patients and family, Gawande reveals the suffering this dynamic has produced. Nursing homes, devoted above all to safety, battle with residents over the food they are allowed to eat and the choices they are allowed to make. Doctors, uncomfortable discussing patients’ anxieties about death, fall back on false hopes and treatments that are actually shortening lives instead of improving them. And families go along with all of it.

You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. These days are spent in institutions—nursing homes and intensive-care units—where regimented, anonymous routines cut us off from all the things that matter to us in life.

As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did. Lacking a coherent view of how people might live successfully all the way to the very end, we have allowed our fates to be controlled by medicine, technology, and strangers.

But not all of us have. That takes, however, at least two kinds of courage. The first is the courage to confront the reality of mortality—the courage to seek out the truth of what is to be feared and what is to be hoped when one is seriously ill. Such courage is difficult enough, but even more daunting is the second kind of courage—the courage to act on the truth we find.

http://www.slate.com/articles/healt...gawande_book_excerpt_on_no_risky_chances.html

 

[Meadbh]

Thank you Midpack, I am going to put that on my reading list. Atul Gawande is a very forward thinker.

 

[donheff]

Thanks. I'm waiting for the library to get it. They have a couple of his previous books so soon, hopefully.

 

[rodi]

It looks like an interesting book. I put a hold for the 1 copy my library system has. I'm 22 on the wait list.

 

[6miths]

I think it is interesting that the idea that 'medicine fails people' when really many of these decisions are individual, family and society based. Where medicine 'fails' the elderly it seems to me that it is for the same primary reason that it fails everyone else in that it has become a business driven by the profit motive.

 

[walkinwood]

Thanks. I read the slate.com article. The "Hope to Die at 75" article convinced me that I need to think about the choices I want for my own end of life - not that I've started doing it. This book, I think, will help in that direction.

 

[6miths]

While I agree with your first sentence, the second may be an overly simple broad brush conclusion. What about the fact that "over 2/3 of the adult population have no Living Will or other advance directive" in the US? Doctors can't follow the wishes of "adults" when most don't even think about end of life questions in advance. Leaving it to doctors or family members has little to do with "profit motive." Profit motive is only one of many end of life issues/factors.

I note you're from CA where things are probably considerably different than the US.

I agree. My main point was meant to be that it is not primarily 'medicine' that is failing and your point about living wills and directives is consistent with my point. Individuals, families and to some extent society as a whole have to take much more responsibility for these things. My secondary point was that in some cases, medical practitioners are hamstrung or conflicted due to the business aspects of medicine.

 

[Meadbh]

I think it is interesting that the idea that 'medicine fails people' when really many of these decisions are individual, family and society based. Where medicine 'fails' the elderly it seems to me that it is for the same primary reason that it fails everyone else in that it has become a business driven by the profit motive.

As a retired physician in Canada, I partly but not completely agree. I worked in an intensive care unit where all the physicians were paid either a salary or a sessional fee. Clinicians had zero financial incentive to overtreat patients. The hospital budget was determined by government, was determined based on previous years' budget and Treaury Boad appropriations, and was usually inadequate to meet patient care needs. We did have a quality improvement culture that emphasized value to patients and cutting out waste. At the end of the year, in line with public accounting standards, any surplus was returned to the Provincial government, and the hospital started again at zero. Retained earnings are not permitted in public finance. There is no profit to be made in Canadian health care, unless you are outside Medicare. Private nursing homes might be in that position, but not public hospitals.

While I was working with children, not elderly people, I personally was involved in many cases where the prognosis was dire, but the parents, often egged on by their religious advisors, were in deep denial and insisted on "doing everything" until weeks later when it became obvious even to them that this was simply torture. The ethical dilemmas associated with this were deeply disturbing to me and were a contributing factor to my decision to RE.

 

[Midpack]

Another good interview/insight into the book/topic FWIW.

Atul Gawande: "We Have Medicalized Aging, and That Experiment Is Failing Us" | Mother Jones

The picture can seem pretty bleak. Many of Gawande's subjects are dealing with the always-hopeful oncologists who, rather than accept the inevitable, coax their patients into trying futile fourth-line chemotherapies that nobody can pronounce. And then you've got hospitals axing their geriatrics departments (aging Boomers be damned) because Medicare won't cover the extra costs of making someone's last years worth living.

But Being Mortal is hopeful, too, and that's why it could make a difference. Most of the changes we need to make aren't expensive. Indeed, some of them could save us a bundle in cash and needless suffering. It turns out, for example, that terminal patients in hospice programs often live longer and better than their counterparts in treatment. In fact, the mere act of talking with caregivers about what you value as you near the end of your life leads to a longer one.

 

[Options]

I have had a will, power of attorney, healthcare power of attorny, healthcare directive and more all conveniently stored with my trust since I was the age of 39. It the next couple years, I will be updating them all as some circumstances have changed. Coming very close to dying then living at a very young age helps one prepare for these end of life matters.

 

[bjorn2bwild]

My secondary point was that in some cases, medical practitioners are hamstrung or conflicted due to the business aspects of medicine.

Atul Gawande wrote several excellent but lengthy articles examining the cost differences in medicine including the business side and related issues - aging and letting go -

The Cost Conundrum - The New Yorker

Letting Go - The New Yorker

The Way We Age Now - The New Yorker

 

[Midpack]

I agree. My main point was meant to be that it is not primarily 'medicine' that is failing and your point about living wills and directives is consistent with my point. Individuals, families and to some extent society as a whole have to take much more responsibility for these things. My secondary point was that in some cases, medical practitioners are hamstrung or conflicted due to the business aspects of medicine.

Fair enough, another case of 'heated agreement.'

 

[MBAustin]

This approach makes much more sense to me than "Hope to Die at 75" - none of us know if this time will come for us at 35, 75, or 95.

I've read several of the articles already and put the book on my reading list (and suggested it to DH also). Thanks for sharing them!

 

[heeyy_joe]

I will watch for it in the discount bin...won't take long.

 

[RonBoyd]

An interesting but disturbing article:

Americans Living Longer as Most Death Rates Fall

Rates also fell or held steady for nearly all the leading causes of death. The one exception: The suicide rate reached its highest point in 25 years. That figure has been increasing since 2000 and "it's really hard to say why," said Robert Anderson, who oversees the Centers for Disease Prevention and Control branch that issued the report Wednesday.

 

[MichaelB]

As much as many people want to bury their heads in the sand ('I want to live as long as possible no matter what') on end of life quality and cost, IMO we'd be better for having thought about it sooner. IMO we owe it to our loved ones, and ourselves.

We have such a strong "can do" cultural attitude in the US. It is almost a core value, and has a very positive impact on other aspects of life and existence. I wonder how much it contributes to the "every possible effort" to keep people alive.

 

[Telly]

Thanks Midpack. I hope to read this book through the library, may be a long time before I can get it.

I have a DNR, medical POA, etc., DW is fine with it, and have talked with our kids to try to be sure that my wishes would be followed. It will all be a moot point if the medical system ignores it.

Talked with my Fire Chief, he says the only DNR-type of order that they recognize is a state registered one here. He directed me to the forms on line. The form requires all sorts of info, and needs two docs to sign off that you are terminal. And then you need to have a bracelet, locket, or something that is in the program with your number on it. In other words, they will do everything they can to deliver you to the ER alive no matter what.
I have asked DW if I suddenly appear to have ceased functioning, to delay calling 911 for quite a while. I of course have no way of knowing in advance if she actually will do this.

And the hospital is a problem. And even at Outpatient Surgery right next door to the hospital (the O.S. is owned by the hospital), the Outpatient registration form asks if you have a DNR, then goes on to say that they will ignore it, any problems they can't handle they will wisk you next door to ER.

From what I have read and heard, the DNR may be next to or totally worthless. Yet some of us got them thinking it would be real, that our wishes would be followed. I don't know if it is a fear of lawsuit or what, but it bugs me.

 

[powerplay]

Here is another article by the same author. It details one woman's journey at the end of life. She was a piano teacher and that passion became her priority in her last days.

http://mobile.nytimes.com/2014/10/05/opinion/sunday/the-best-possible-day.html?_r=3&referrer

 

[rodi]

Thanks Midpack. I hope to read this book through the library, may be a long time before I can get it.

I have a DNR, medical POA, etc., DW is fine with it, and have talked with our kids to try to be sure that my wishes would be followed. It will all be a moot point if the medical system ignores it.

Talked with my Fire Chief, he says the only DNR-type of order that they recognize is a state registered one here. He directed me to the forms on line. The form requires all sorts of info, and needs two docs to sign off that you are terminal. And then you need to have a bracelet, locket, or something that is in the program with your number on it. In other words, they will do everything they can to deliver you to the ER alive no matter what.
I have asked DW if I suddenly appear to have ceased functioning, to delay calling 911 for quite a while. I of course have no way of knowing in advance if she actually will do this.

And the hospital is a problem. And even at Outpatient Surgery right next door to the hospital (the O.S. is owned by the hospital), the Outpatient registration form asks if you have a DNR, then goes on to say that they will ignore it, any problems they can't handle they will wisk you next door to ER.

From what I have read and heard, the DNR may be next to or totally worthless. Yet some of us got them thinking it would be real, that our wishes would be followed. I don't know if it is a fear of lawsuit or what, but it bugs me.

That is disturbing to me. I can kind of see the paramedic thing But hospitals should honor the DNR.

What state is this in. I don't believe you have to register DNRs in CA or CO (states where I dealt with hospitals while family members were terminal and dying.)

 

[Brat]

I think she was referring to a POLST National POLST

These are designed for the seriously ill and frail. They only signature by you and your physician. POLST Oregon

In Oregon, on October 27, 1997 Oregon enacted the Death with Dignity Act which allows terminally-ill Oregonians to end their lives through the voluntary self-administration of lethal medications, expressly prescribed by a physician for that purpose. This required the signature of two physicians confirming the diagnosis and an evaluation by a psychiatrist or psychologist to assure that this is a decision by the patient alone and are of sound mind. Death with Dignity Act

In the news recently is a relatively young woman from California who has a cancerous brain tumor who moved here to take advantage of this law. Brittany Maynard: My right to death with dignity at 29 - CNN.com

 

[Telly]

That is disturbing to me. I can kind of see the paramedic thing But hospitals should honor the DNR.

What state is this in. I don't believe you have to register DNRs in CA or CO (states where I dealt with hospitals while family members were terminal and dying.)

Texas. Here is a link to the state form: Texas Out of Hospital Do Not Resuscitate Program - Texas Department of State Health Services, EMS & Trauma Systems

The Fire Chief explained to me that the original purpose of this program was for out of hospital, like in nursing homes. But that FDs are using the concept - they have to see the registered bracelet or other marker to know that the patient is indeed in that program. Otherwise, they do all they can to resuscitate.

I looked at the form online again today, I was wrong, does not have to be terminal. But I sure thought the last time I looked that it took two docs to testify on it for a person that was in control of their senses when applying. Now I see only one doc required. But either way, I don't think any doc around here is going to sign it for a patient that is OK and doing just fine at present.

And I think hospitals do whatever they want, if a patient comes in not functioning, or becomes that way in their care. My opinion - to try avoid any possible lawsuit, they do all they can so no one can later say poor Uncle Joe did not get timely and proper treatment after arriving at their hospital - just my opinion.
I am reminded of the line in the song "It's Good News Week" (Hedgehoppers Anonymous) from the 1960s.

 

[rodi]

I'm not sure that doctors would refuse to sign for patients that are currently ok. It seems rather like a standardized living will. These are the type of things to think about BEFORE you get dementia, a terminal illness, hit by a car, etc....

FWIW - the living will and patients wishes can go both ways. My parents both had directives to exclude extraordinary measures. My brother's directive was to do EVERYTHING possible. He had terminal cancer with ZERO chance of a cure but because of his wishes he had 5 or 6 major surgeries in his last weeks to debulk the tumors for "comfort"... (It had the opposite effect).

My husband and I have advanced directives written up. We're both healthy. After observing my parents and my brothers last days I know for a fact I do not want to be intubated if I have a terminal condition. Especially after my mother extubated herself and croaked out DNR!!!! when the nurse wasn't looking.

 

[RonBoyd]

On getting old:

 

[iac1003]

Now, that (the video) was funny.

Seeing patients exclusively in nursing homes gives me a skewed view of aging and dying. The number of medications people are on is dizzying. Then I add more to the mix.

I hope to not be one of them.


Sent from my iPhone using Early Retirement Forum

 

[RonBoyd]

http://newoldage.blogs.nytimes.com/2014/10/10/as-diseases-are-managed-lifespans-keep-getting-longer/

Not the article I mentioned earlier but...

Correction: October 10, 2014
Because of an editing error, an earlier version of this post incorrectly described the relationship between suicide rates among those aged 65 and older and the overall suicide rate. A recent increase, not decrease, in suicide among the elderly has not significantly increased the overall suicide rate, according to Robert Anderson, chief of mortality statistics at the National Center for Health Statistics.

The important take-away from the article, however, is this:

People who reached age 65 could look ahead to an average additional 19.3 years on the planet, an all-time high. Men could anticipate another 17.9 years, on average, and women another 20.5.