Being Mortal by Atul Gawande

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In Atul Gawande’s well written book “Being Mortal” talks about real life situations on end of life decisions. He demonstrates what people should be ready for when death is near, and makes it extremely clear that each person has their own path, and way of deciding for themselves which path to choose. He summarizes his conclusion of the book by explaining that the person who is dying should be allowed to offer the family guidance on their wishes. Even if it’s in a subtle way, the family should try to accommodate what those wishes are, even if their dying loved one cannot speak sensibly, and even if those wishes shorten one’s life.

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Atul Gawande states, “We’ve medicalized mortality”. I believe the term “medicalized” means that the medical field looks at patients as something to treat rather than to heal, something to fix rather than to mend. We as medical professionals have placed more meaning on the patient being medically cared for and treated and not enough importance on the emotional well being of the patient.

For example is the patient joyful? Does the patient feel motivated to do things they life and see friends/family? I believe these are the questions we should be asking ourselves. When you stop seeing a person for their thoughts and feelings and as just someone that needs to be “fixed” it’s easier for medical doctors to give them their options and just walk away. I believe that the training of medical doctors is in need of an immense overhaul.

The medical community should be trained to address death not as something to treat and fight, but as an individual experience for each person that is confronting it. Every patient is unique and each of his or her thoughts on death and dying may be different.

Atul Gawande talks about the death of Ivan Llyich and illustrates the idea on suffering the control that medical doctors can have over someone. His story truly tests the power and limits of medicine. In medicine today, I feel as though we are becoming more accepting of the idea that pain and suffering must be displaced from the dying experience. We all should have a right to be free of physical pain, yet the power that the medical community has over that is something different. Pain relief should never be denied when it is needed, But, for some people like Ivan Llyich the pain of dying is a route to understanding of ones self. Although many people would desire a painless and quick death without suffering, others would have some alternative as to what seems to be a “good death”. Some may want a conscious death, one that comes with acceptance.

Drawing from my personal experiences working as a nurse at the bedside for the past 10 years, I had an experience with a patient who was admitted to our unit and been on high doses of opioids for pain management at end of life. We had adjusted his medication to allow him to be more alert and interactive with family. As time passed his mental status declined, and he could only answer certain questions about his pain level. According to the medical staff on our unit we felt as though we achieved our goal of good pain control and side effects, but his mother disagreed. For this reason and some others, we could no longer keep him in our care. The patient was enrolled in hospice per his mother’s request and with high doses of morphine given every hour at home, he died the next day. I don’t believe anything can change medicine and its protocol but believe we can do a lot more when it comes to palliative care. We as medical professionals should be giving our dying patient the freedom to make his or her own end of life decisions. I believe the value of ones life has to do with their attitude, and there will to live.

In Chapter 4 of the book, Atul Gawande describes the birth of the assisted-living facility concept (Park Place), designed by Keren Wilson to provide her disabled mother, Jessie, with caregivers who would not restrict her freedom. The vital wishes included her having her own thermostat, own schedule, her own furniture, and the ability to lock the door. I believe what it means to treat someone with serious infirmities as a person and not a patient or diagnosis is to treat a person with dignity and compassion, and not seeing them as a disease but as someone with feelings. It’s important to give these people the independence to make their own choices, including their own schedule.

As the book represents, many times patients are limited to schedules and timetables associated with their disease or illness. Personally, we should think of these types of patient’s interests- things they enjoy doing for example- card games, listening to music, friendly conversation. All of these things should be apart of their treatment plan. We should be asking them how they feel, and what they think rather telling them what to do. People should always have the right to make their own decisions concerning their care, unless they have dementia and can no longer make appropriate decisions for themselves. In the end, people who are able to make choices for themselves live a more fulfilled life.

Reading about Bill Thomas’s Eden Alternative in Chapter 5, he defined the Three Plagues of nursing home existence, which included boredom, loneliness and helplessness. In eldercare what I envision matters most is to know that someone cares about you and your needs. I remember as a child I would always ask my parents to let me do things on my own, if adults would support that, ones sense of self would be allowed to grow. When we are young, we wanted the right to make our own decisions, whether it be to drive or take public transportation. When we get older we have those choices taken away from us, and as a result we loses parts ourselves and being independent. What we need is to be able to recognize ones self. Fighting the Three Plagues via Bill Thomas’s Eden Alternative should be at the forefront of thinking on eldercare, and we should make every effort as healthcare workers to make sure elders are living fulfilled lives. I truly believe that it’s about the quality of life not the number of our days on earth that matter.

Atul Gawande points out that a medical student’s education has not traditionally included education on helping a patient cope with grief .End of life training can change our experiences regarding end of life care. A loved one dying is never easy to face, and has becoming still very challenging in the era of high tech medicine. End of life often comes after recurrent surgeries, large amounts of medication, painful side effects, and endless talks with specialists. We have become so practiced at extending someone’s life that death often comes after months of coping with several illnesses. I think most people would not choose to suffer in this way, but current medicine does not help with this important decision. While speaking about an advanced directive is the typical route, for many medical professionals its not sufficient in helping families with the process of making end of life decisions. I believe that we as nurses are in a perfect position to help these patients along with their families through this type of decision-making. It is often disregarded because most people are uncomfortable in talking about death and dying.

Nurses and medical doctors can alleviate the process by being clear spoken, avoiding euphemisms and making expectations and goals of care clear and concise. It’s important for medical professionals to feel comfortable talking about end of life care and help patients and families remain hopeful and optimistic. So my question is, how can we get to this point? I believe that end of life conversation training needs to be incorporated in all nursing and medical school programs. With the use of communication skill experts, we can come up with a model to address the training gaps for nursing and medical learners. These types of people could teach us to assess the patient’s present understanding of their disease before giving them tough news. We as medical professionals could learn techniques such as listening for indications of distress, and by teaching us specific phrases to use such as “tell me more”, which can take a more compassionate approach.

Atul Gawande suggests using four key questions he learned from palliative care colleagues to expand the scope of how we work with patients. These questions I believe are not just for end of life situations. They are pertinent for any situation people face, and are in tune with our patients and their individual needs and desires. The questions are simple, and well thought out in order to help someone accept what is to come with grace and dignity. I believe that asking these types of questions allows everyone to comprehend what the objective really is and what we are trying to achieve. As medical professionals we discuss whether our patients want medical treatment with a terminal diagnosis that will likely end in death, and the patient is not aware of their destined outcome.

Most patient will say they don’t want aggressive treatment under those conditions. Yet, we don’t have a good way for patients to speak about their wishes to their loved ones when the issue may be quality vs. quantity of life. Sadly, patients often cannot depend on their doctors to speak simply, since as Dr. Gawande makes apparent, doctors do not get much education, if any, on telling patients they have a illness which is killing them or that they have ran out of possible medical solutions. These questions will help health care professionals with just that. This will obviously not be an easy conversation to talk about and these questions will help transition in to that. The questions offer many ways to open the conversation, and narrow in on what important things should be discussed.