Being Mortal by Atul Gawande

I finished this intriguing book about how we care for the aging and dying. I made notes as I read:

• Doctors should improve at giving their patients guidance and sympathy when they are facing death.  Doctors should talk honestly about death with their patients.
• People live longer than ever before.  Most deaths used to occur in the home; now, death is handled by medical professionals.  Why the change?
• Old age used to be rare.  Those who survived to old age commanded respect in society as keepers of tradition and knowledge.  Now, old age is not rare.  People can get knowledge from technology, like computers.  Consequently, veneration of old age has been replaced by veneration of the independent self.  People are more independent than before and move farther away from home as adults, becoming less reliant on family.
• The primary view on how we age is that we wear down over time.  Essentially, parts of us begin to fail; eventually, there are too many failing parts to overcome.
• Early in the twentieth century, many people lived in poorhouses.  Although nursing homes and assisted living facilities are a modern day better option, they are often disliked by the elderly.  The reason is that it is not “home” to them.  They are unable to live their lives as before, with the comforts and routines they are used to.  In nursing homes and assisted living, people lose control over their lives and instead live in controlled, sterile environments.  Their care controls them instead of their controlling their care.
• “For most of our species’ existence, people were fundamentally on their own with the sufferings of their body.  They depended on nature and chance and ministry of family and religion.  Medicine was just another a tool you could try, no different from a healing ritual or a family remedy and no more effective.”  However, in the middle twentieth century, advances in medicine gave people hope that medicine could cure them.
• With social security, people had the financial means to move out of poorhouses.  However, poorhouses remained populated because they housed many people who were physically unable to live independently.  Over time, society shifted people from poorhouses to hospitals.  Hospitals, however, couldn't meet the demands of so many people.  The result was that nursing homes were created.
• The first assisted living facility opened in 1983.  The founders wanted a place where the elderly controlled their care.  Over time, however, it fell into the same problems of bureaucracy.
• Research shows that giving elderly in nursing homes a reason to live can extend their lives and reduce their dependence on prescription drugs.  The three plagues of elderly living are: boredom, loneliness, and helplessness.  Eradicating these can drastically improve the lives of the elderly.
• Eldercare should be about not only making their lives safe, but also making their lives meaningful.
• 25% of Medicare costs are for the 5% of patients in the final year of their life.  Medical costs are often enormous in the last few months of patients’ lives.  Why spend so much money on someone who will only die?  At what point should treatment be stopped?
• Studies show that patients who have discussions with their doctors about end-of-life care are more likely to die with peace and in control of their situation and less likely to undergo potentially wasteful treatments.
• Scholars posit three stages of health care, corresponding to the development of the country’s economy.  First, when the economy is poor, most deaths occur in the home.  Second, as incomes rise, people can afford access to medical care and go to the hospital.  Deaths occur predominantly in the hospital.  Lastly, as incomes reach their highest levels, the trend reverses and people die in the home because they care about their quality of life.  In the U.S., most people died in the home up to 1945.  Then, into the 1980s, it was hospitals.  Now, people are returning to the home to die.