Not Your Typical Summer Beach Read
I bought Being Mortal a few years ago on a date night with my wife. We grabbed dinner and stopped through Scuppernong Books to judge books by their covers. We each bought a book and laughed that my choice was a surgeon’s thoughts on “medicine and what matters most in the end”…while hers was something from her go-to genre: Young Adult Post Apocalyptic Fiction.
While mine might seem like a strange choice, Being Mortal has become one of the easiest books for me to recommend. For someone with 9, 7, and 4 year-old kids, I read a decent number of books (I’m up to 11 this year.) But I always cringe and have to think hard when someone asks me what I’m reading now and if I recommend it. I have to qualify it with statements like: “What do you think about historical biographies? No? What about historical fiction? Oh ok, you try to stay away from history altogether. What about a book on the current state of the prison system? Right. Ummm….what about a book on prayer? Or post-apocalyptic fiction? What about one on productivity?” (Note: if you answered yes to any of those, the hyperlinks above are some recommendations from what I have read this year.)
But to find out if Being Mortal would appeal to someone, I can simply ask: “Do you care about someone who will likely die in the next 30 years? If so, you need to read this book.” I admit, the publisher probably doesn’t want to put that on the book jacket, but it sure works as a qualifier.
“If end of life discussions were an experimental drug, the FDA would approve it” – Dr. Atul Gawande
While a book on death and dying might seem too dry (if not depressing) for anyone not immediately going through it, the author brings relevant personal stories that make the subject highly approachable. But it is about so much more than simply anecdotal stories. A Harvard professor and practicing surgeon, Gawande also fills the book with studies and statistics that go against the conventional wisdom.
The premise of Being Mortal is to examine how we approach medicine, living arrangements, and conversations with family and medical professionals in the final days, weeks, years and decades of our lives. A far reaching book, Gawande touches on the history of assisted living and retirement communities while detailing how older persons are changing their living habits over time (and how that differs across socioeconomic lines.) He also takes a deep dive into the role of hospice and palliative care instead of (and along side) further potentially life-saving treatments.
“Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be. We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?”
It is jaw-dropping to realize the costs involved in end-of life care. Gawande points out that 25% of all Medicare spending is for the 5% of patients in the final year of their life. Most of that care is in the final few months.
However, end-of life discussions are about far more than costs or even about the patients’ own desires. The reason this book is a must-read is for how Gawande emphasizes the role of “others” in this discussion. The final stage of life does not happen in a vacuum; the author gives weight to the role of loved ones in the discussion.
Are We Prolonging or Increasing the Quality of Life – or Neither?
Most eye-opening to me was Gawande’s perspective, as a surgeon himself, of the harm we’re actually doing in medicine. Specifically, he points out that while we have been able to “prolong” life, medical advances have actually decreased the quality of life in the final periods of patients’ lives. Gawande points out:
“A landmark 2010 study from the Massachusetts General Hospital had even more startling findings. The researchers randomly assigned 151 patients with stage IV lung cancer, like Sara’s, to one of two possible approaches to treatment. Half received usual oncology care. The other half received usual oncology care plus parallel visits with a palliative care specialist. These are specialists in preventing and relieving the suffering of patients, and to see one, no determination of whether they are dying or not is required. If a person has serious, complex illness, palliative specialists are happy to help. The ones in the study discussed with the patients their goals and priorities for if and when their condition worsened. The result: those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives—and they lived 25 percent longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.”
The Role of Physicians
One of the most fascinating aspects of Being Mortal is the reader gets to see behind the curtain to the doctor’s side of the table, which is where many of the problems lie. Gawande believes the medical community is “dispensing the medical equivalent of lottery tickets” because as patients, we often want to fight until we hear “there is nothing more we can do.” The problem comes when the medical community rarely has nothing more they can do. There is always another experimental test or drug, but at what financial cost, at what personal cost to the patient, and what emotional cost to their loved ones?
Gawande details a study of 500 terminally ill patients, in which doctors were asked to estimate the patients’ life expectancy: 63% overestimated and only 17% underestimate. Startlingly, the average estimate was 532% too high and the better the doctor knew the patient, the more likely they were to be wrong. Similarly, another study found that while doctors often tell patients when an illness is incurable, 40% of doctors in the study would offer treatment that they did not believe would work, just to “try something.”
The biggest takeaway is to open up the honest dialogue: with physicians, with patients, with family members. As a financial planner the book was especially insightful. Obviously it was helpful to think through end of life care and costs, but more importantly, it was insightful to see our role as a sort of “financial surgeon” for our clients. I couldn’t help but see the correlation between how doctors interact with their patients and how we interact with our clients. Many advisors try to solve a financial problem with “a new and better treatment” in the form of a new stock, mutual fund, or method of investing. I was encouraged to hear Dr. Gawande ask his patients many of the same questions we ask: What is most important to you? What are you willing to give up? What are you not willing to give up? When are you happiest? When are you the most uncomfortable?