Death-quote_3

If you are reading this blog, it means you are alive – you should read ‘Being Mortal’ by Atul Gawande the best selling New York Times author, surgeon, researcher and dilettante.

It does not matter whether you are a clinician, researcher, administrator etc. If you are connected to healthcare in anyway, even as a patient, you should read this important, deeply moving and insightful book. Although this book itself will not change your whole life, it could ‘very well shape how it ends’. This blog is about ‘Being Mortal’ and related events connected to the launch of the book from all over the world.

AG_BM_2When I was reading ‘Being Mortal’, I realised what little we were taught about death and dying at medical school. Practically nothing. No, that is not exactly true because we started leaning medicine by dissecting a human corpse. We were introduced to dead bodies who were are not mortal, they were already dead. It seems in this era of technology, doctors are there to prevent death, keeping people ‘alive’ or at least to delay death as much and as long as possible. Furthermore, fatal diagnosis, terminal illness, dying and death are very uncomfortable topics to discuss with patients and their families. I thought this was only in economically developing countries such as Sri Lanka, where I had my medical training. However after working in Australia for a decade I have realised that its almost the same – we shy away or avoid talking about the ‘last lap’.

Being Mortal gives an in-depth insight into how fatal/terminal diseases are handled by clinicians, how ageing people are cared for in the US, as well as a glimpse into old age in the authors

Being Mortal gives an in-depth insight into how fatal/terminal diseases are handled by clinicians, how ageing people are cared for in the US, as well as a glimpse into old age in the authors native country, India. It describes the evolution of retirement homes, nursing homes, aged care facilities and hospices. It gives an in-depth description and analysis of the newer models of care named ‘assisted living’ for the ageing and the terminally ill. The authors unique experience with his own father’s (urology surgeon by profession) fatal disease and his inadequacy in managing his own patients brings this book close to a personal experience for many clinicians.

While reading ‘Being Mortal’ within a few months of its launch, I found that the topic came up at very different forums – journals, blogs, websites, TV shows, YouTube, Twitter etc. I thought it would be good to share the perspectives from different people – clinicians, media editors, patients.

You could listen to Gawande talking to the Mosaic editor on YouTube. It gives a short synopsis of his book. The eminent JAMA editor George Lundberg states the five key clinical questions Gawande recommends that needs to be asked of a fatally ill person who has ‘exhausted the potential of scientifically based curative therapies and it becomes just a matter of time for nature to take its course’

1. What is your understanding of your current health or condition?

2. If your current condition worsens, what are your goals?

3. What are your fears?

4. Are there any tradeoffs you are willing to make or not?

And later,

5. What would a good day be like?

‘Dying seems to in the air’ in 2014, as another book Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life was published by the Institute of  Medicine (download a free copy). According to Lundberg, the 507 page long book was informed by years of study and many hundreds of references, and includes many recommendations for dramatic and needed improvements. Gawande interviewed more than 200 people about their own experiences with ageing or serious illness, or the experiences of a close family member. Thus, Gawandes’s book is not a scientific study, but it is supported by scores of relevant insightful anecdotes. Lundberg concludes that ‘These are two books with very different pedigrees yet remarkably similar findings and recommendations, which are all very different from common current American medical practices at the end of life’. Sarah Kliff writes in Vox how ‘Americans’ refusal to talk about death hurts the elderly’. A related topic of ‘Breaking bad news’ in Mosaic describes how doctors learn and cope with telling patients about serious illness or dying.

Is future of medicine connected to ‘Being Mortal’? You will find out if you listen to the series of lectures by Gawande (Reath Lectures BBC) which has generated wide ranging discussions around death, dying and future of medicine. The first in the series is about why doctors fail. Gawande explores the nature of fallibility and suggests that preventing avoidable mistakes is a key challenge for the future of medicine. In the second lecturehe argues that better systems can transform global healthcare by radically reducing the chance of mistakes and increasing the chance of successful outcomes. Gawande calls for a new approach to the two great unfixable problems in life and healthcare – ageing and death in his third lecture and tells the story of how his daughter’s piano teacher faced up toterminal cancer and the crucial choices she made about how to spend her final days. In the final lecture in India calls for a new focus on medical systems to ensure doctors work more effectively, alongside far greater transparency about their performance.

Using the Twitter hashtag #BeingMortal people shared their own stories in relation to Gwandes’s book which was truly a human experience worth looking at.

The evergreen controversial BMJ editor Richard Smith wrote an very interesting blog titled ‘Dying of cancer is the best death’ which generated a lively discussion, some very critical especially from parents who had children with cancer. One of the more positive comments was titled, ‘How to achieve a good death’. Smith replied further explaining his position regarding the ‘death debate’. Continuing the discussion on being mortal Smith poses another interesting question ‘Would you like to die at 75 or 150?‘ based on two other articles. Oncologist and ethicist Ezekiel J Emanuel explains why he wants to die at 75 and Dr Joon Yun, physician turned investor, is offering $1 millionas The Palo Alto Longevity Prize to live up to 150 years.

We have all lost a friend or a colleague. Ranjana Srivastavawrites on the ‘Death of a Colleague’ in her NEJM column which will make us think of situations that are difficult to come to terms with especially when an active colleague/mentor dies unexpectedly.

On learning of his terminal cancer, Oliver Sacks, professor of neurology and author of many books including ‘The man who mistook his wife for a hat’ has written this insightful piece in New York Times about ‘My Own Life’. Writing a review about ‘Being Mortal’ before he learnt about his fatal disease, Sacks states,“We have come to medicalise ageing, frailty, and death, treating them as if they were just one more clinical problem to overcome. However, it is not only medicine that is needed in one’s declining years but life – a life with meaning, a life as rich and full as possible under the circumstances. Being Mortal is not only wise and deeply moving, it is an essential and insightful book for our times, as one would expect from Atul Gawande, one of our finest physician writers.”

In a beautiful post Lisa Bonecheck Adams who suffered from metastatic breast cancer writes what to say “When I die…..”

Kumara Mendis