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Thursday 10 September 2015

Review: Atul Gawande, Being Mortal

This is a very well written and very interesting book. It argues that the elderly frail and the dying can enjoy a better quality of life than they often do - and that will often enough involve less medicine than more. It will certainly involve asking the frail and the dying what their own priorities are.

Gawande contrasts nursing homes, organised like penitentiaries, unfavourably with assisted living where even the very frail can keep something like their own front door and the freedom to schedule their own time and occupy it in their own way. Likewise, he is more impressed with hospice care (including hospice care delivered at home) than with medical interventions which go on for too long and often reduce rather than improve quality of life.

The argument is built up through some very finely written informal case studies, including one of his own father. As a result, the book is very easy to read - though, of course, it deals with end of life issues which are often enough traumatic for those involved - the person who is on the way out and the family who will remain. He also looks in detail at the ideas of practical providers who have sought alternatives to over-medicalised, over-hospitalised management and intervention.

I felt that the argument Gawande advances is really more general than he indicates. Even before we get into frailty and end of life, modern medicine often offers us too much and expects us to take it. 

It is now routine, for example, to offer rather unpleasant and often risky procedures as the means by which certain things (usually cancers) can be ruled out. But a good specialist using his or her hands and collateral information could in at least some cases make a reasonably reliable assessment. I would like the option of declining the invasive procedure until I had had a judgment from a pair of hands that concluded there was a real cause for concern.

Likewise, with medication. It is not only the elderly frail who are over-medicated to the point where side-effects are worse than the problem being medicated for. Play-safe prescribing or prescribing-on-request puts many millions of people onto pills they don't really need. 

There are signs that the problem is being recognised and  that things are changing. I hope so.

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