Sunday, May 02, 2021

Being Mortal and Atul gawande:

Notes and Beauty Sentences:
  1. Aging: As you know, we lose bone density. But our soft tissues like arteries and soft tissue pick up calcium and become crunchy to the Touch. To maintain the same volume of blood flow through or narrowed and stiffened blood vessels, the heart has to pump harder against the increased pressure. Therefore, peak output of the heart decreases steadily from 30.
  2. The body just break down from the backups of one extra lung, extra teeth and extra kidney..  Averting our eyes from these realities as much freedom as possible from the ravages of disease, retention of enough function to actively engage with the rest of the world.
  3. Assisted living is harder than assisted death. The Dutch has 1 in 35 requested for assisted suicide in 2012. It is not a sign of success but failure.
  4. Being mortal is about the struggle to  cope with the constraints of our biology, with the limits set by genes and flesh and bone. Medical science has allowed us to push against those limits but such power is limited and will always be.
  5. In almost every case, no one does anyone sit down with you and try to figure out what living a life really means to you under the circumstances, let alone help you make a home where that life becomes possible. This is the consequence of a society that faces the final phase of the human cycle by not thinking about it.  We end up with institutions that address any number of societal goals, but never the goal that matters to the people who reside in them: how to make life worth living when we are weak and frail and unable to fend for ourselves any more.
  6. With animals for companions, even patients with dementia that has lost the ability to grasp much of what was going on could experience a life with greater meaning and pleasure and satisfaction. It is much harder to measure how much more worth people find in being alive than how fewer drugs they depend on or how much longer they can live. But could anything matters more ?
  7. Psychologist Laura Carstensen : Page 97: how we choose to spend our time may depends on how much time we perceive to have.
  8. As our time winds down, we all seek comfort in simple pleasures. We become less interested in the rewards of achieving and accumulating, more in the rewards of simply being. Yet while we may feel less ambitious, we also become more concerned for our legacy. We have a deep need to identify purposes outside of ourselves that makes living feel worthwhile and meaningful.
  9. Medicinal professionals focus on the repair of health, not the sustenance of soul. We put the date of our waning days in the hands of these people who are valued for their technical prowess than for their understanding of the human needs.
  10. The battle of being mortal is the battle to maintain the integrity of one’s life - to avoid becoming so diminished  that who you are becomes so disconnected from who you were.   But at least, We have entered an era in which an increasing number of medical professionals  believe that their job is not to confine people’s choices, in the name of safety, but to expand them, in the name of living a worthwhile life.
  11. People with serious illness have priorities besides simply prolonging their lives.
  12. In the past, dying was typically a more precipitous process, we do not need to think about helping people to achieve what is important to them at the end of their lives. But now we live on for decades in a diminished self.
  13. The difference is in the priorities. In ordinary medicine, the goal is to extend life - sacrifice the quality of your existence now- doing surgery- for the chance of gaining time later. Hospice helps people with a fatal illness to live the fullest possible life right now. It means focusing on freedom from pain, maintaining mental awareness for as long as possible.
  14. Hospice - 99% know they are dying, 100% hope they are not.
  15. Hope is not a plan, but hope is our plan…
  16. Our every impulse is to fight, to die with chemo in our veins or a tube in our throats. The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine we can wait till the doctor tells us there is nothing else they can do.   But there is rarely nothing much that the doctors can do.
  17. Palliative language: not “I’m sorry things turn out this way”, but “I wish things are different”. Not “what do you want to do when you dying”, but “if time becomes short, what is the most important to you?”
  18. I need to understand how much you are willing to go through  to have a shot at being alive and what level of being alive is tolerable to you:
    • Do you want to be resuscitated if your heart stop
    • Do you want aggressive treatments like mechanical ventilation
    • Do you want tube of intravenous feeding if you can’t eat on your own?
  19. People die only once. They have no experience to draw on. They need medical staff who are willing to have the hard discussions and say what they have seen, who will help people prepare for that is there to come.
  20. Expressions that put you together with the patient: “I am worried” - not just telling the facts, but conveying that I am worried, I am conveying both the seriousness of the situation but that I am on her side.
  21. “Ask,tell, ask” - ask patients what they want to hear, tell them, then ask if they understood.
  22. The choices don’t stop. Life is choices, and they are relentless. No sooner have you made one choice than another one is upon you.
  23. Assisted living is far harder than assisted death, but its possibilities are far greater as well.  
  24. Being mortal is about the struggle to cope with the constraint of our biology, with the limits set by genes and flesh and bone. Medical science has given us the powers to push against these limits, but I have see the damage we  in medicine do when we fail to acknowledge that such power is finite and always will be.
  25. We have been wrong about our job In medicine. We think our job is to Ensure health and survival. But it is also to ensure well being.
  26. The field of palliative care has emerged over recent decades to bring this kind of thinking to the care of dying patients. And it is advancing, bringing the same approach to other seriously ill patients, whether dying or not. This is cause of encouragement but not celebration. That will be warranted only when all clinicians apply such thinking to all persons they touch. No seperate speciality is required.
  27. When I was a child, my father taught me never to accept limitations that stood in my way. As an adult watching him in his final years, I saw how he came to terms with limits that simply could not be wished away.when to shift from pushing against limits to making the best of them is often not readily apparent.
  28. The 4 questions:
    • What is the understanding of the situation and it’s potential outcomes
    • What are your fears and your hopes?
    • What are the trade offs you are willing to make  and not willing to make ? Do you want to stay alive as Long as you can eat ice cream and watch TV?
    • What is the course of action that best serves this understanding?

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