Atul Gawande Being Mortal Summary

Atul Gawande’s book, Being Mortal, focuses on end-of-life care for patients in the American healthcare system. Gawande includes evidence along with anecdotes from his own life surrounding his career as a surgeon and his role in helping family members navigate their own end-of-life decisions. Much of Gawande’s argument rests on the premise that while end-of-life care in the American healthcare system is heroic and equipped with the best possible advancements in medicine, it too often fails the patients it is supposed to help. A large part of Being Mortal focuses on the doctor-patient relationship (especially in the context of shared-decision making) and how we often fail to recognize the things that are most important for our elderly in their

final stages of life. Instead of focusing on improving the quality of life at the end of their years, we often focus on extending merely the number of years of life. Additionally, healthcare providers often provide medically intensive and invasive (and usually, expensive) treatments that often have little chance of greatly improving patient outcomes, if not worsening them.

Such decisions often come at a great cost to the healthcare system, and at a greater emotional, psychological, and social cost to the patients and families of these patients who are receiving such treatments.
Gawande’s book is very pertinent to the present day and has by many accounts sparked a national discussion on end-of-life care and how we treat our elderly. With elderly people accounting for a greater proportion of the American populace and as people start living even longer than they do now, end-of-life care will become and remain a major issue faced by doctors, patients, their families, and the healthcare system. Additionally, with our greater focus on improving patient outcomes while getting the most value for our healthcare dollars, end-of-life care is a major area that healthcare systems and hospitals will focus on, as it accounts for a large portion of their budget. As a response to the need to take care of our aging population, hospice care and palliative medicine are some of the newer specialties in the medical field that have been increasing in popularity and more research needs to be focused in these areas to better understand how to improve patient outcomes.

End-of-life care has been identified by the Institute of Medicine as one of the priority areas to improve quality of health care.1 Most of the current evidence is derived from literature that focuses on patients with cancer – therefore, current guidelines as they relate to all terminally ill patients may be misguided.2 In Being Mortal, Gawande advocates for versions of hospice care and palliative medicine that allow the elderly or those facing a terminal illness to come to terms with their fate in a way that is respectful and peaceful. Gawande relates tales of our past ways of letting the elderly die at home to the shift to present day, where we often place the aging in nursing homes and take away a lot of their autonomy. As much of the western world has shifted from large extended family networks to more nuclear families, elderly people often cannot rely on the family to support them into old age, as used to be the case. In contrast, Gawande gives us an anecdote about how his grandfather lived a fulfilling life in rural India (until 110 years old!) as an example of how elderly people in certain non-westernized countries (such as India) can rely on family support into old age and maintain their autonomy relatively well, even while living in a setting that doesn’t have the most advanced medical capabilities and technologies.
While data on end-of-life care is limited, there is evidence supporting many of Gawande’s positions. One study utilized a cross-sectional national survey to understand the factors considered important during the end of life among seriously ill patients, recently bereaved family members, physicians, and other health care providers.2 Of 44 attributes of quality at the end of life (ranked on a 5-point Likert scale), eight items received strong importance ratings from patients but less from physicians (p < .001), including being mentally aware, not being a burden, helping others, having funeral arrangements planned, and coming to peace with God.2 This study provides evidence that there are certain pressing areas that physicians often neglect that terminally ill patients find important and need to be addressed. In a separate national study, a follow-back survey was conducted among family members of patients who had died in an institutional setting (hospital or nursing home) versus family members of those who had died utilizing a hospice service (home or inpatient setting) to examine the difference in the adequacy or quality of end-of-life care between these settings.3 More than 33% of respondents cared for in an institutional setting reported insufficient emotional support for the patient, compared with about 20% of those receiving hospice services.3 On the measure of being treated with respect at the end of life, hospice service patients were the most likely to report satisfaction (96.2%), followed by hospital patients (79.6%) and nursing home residents (68.2%). 3 Lastly, 70.7% of family members of patients receiving hospice services rated care as "excellent" compared with less than 50% of those dying in an institutional setting (p < .001).3 This study provides support for the growing movement of hospice care as a more humane and personal way to treat our terminally ill patients.
Gawande’s opinion is consistent with most of the evidence that has come out regarding the topic.

Many of his suggestions provided revolve around training doctors to better assist patients in end-of-life care decisions and to ask pertinent questions and have frank discussions on the matter that encompass more than just medical care, which is what much of the literature provides. However, while many of these suggestions can be implemented, one relevant question is whether healthcare providers, when faced with these critical junctures, always have the time to do so, especially if it is a time-sensitive intervention that requires quick thinking. This may be why Gawande advocates for planning beforehand with the family/patient regarding their desires for end-of-life care, so that if this critical juncture is reached, the best decision is made that accords with the wishes of the

patient.
A present-day healthcare practitioner who deals with elderly patients or end-of-life care would find many ideas discussed in this book pertinent to their practice. For example, a doctor dealing with an elderly patient with little chance of survival would benefit by having discussions regarding end-of-life care with patients and families or could at least start by educating themselves on how to do so. Doctors often don’t discuss end-of-life care with patients and their families to figure out what the patient wants to get out of the end of their life, as they may become so focused on treating the pressing physical needs of the patient that they neglect their emotional, psychological, and spiritual needs, among others. Lastly, as American healthcare has moved away from paternalistic care to patient-centered medicine where patients have most of the say in their care, this has led to a greater respect for patients’ rights but can also have some negative outcomes. Gawande advocates for a shared-decision making model, where, instead of simply laying out options and overwhelming the patient with the choices (patients, when faced with the very real possibility of death, often choose that path to extend life, even if very invasive), doctors lay out treatment options for patients but help guide them in the direction of an option that makes the most sense given the probable treatment outcomes and the wishes of the patient and the family. Gawande, in effect, advocates for a larger overall culture-shift in our way of thinking about death and the elderly. It is important to note, however, that he does not advocate for actively assisting patients to their death. He instead advocates for doctors to become more aware of their roles not just as battlers of disease, but as professionals in tune to a patients’ and families emotions, hopes, and fears. This, he argues, would lead to a more dignified life, and death, for the patient.