Quotes from Atul Gawande

Consider the case of La Crosse, Wisconsin. Its elderly residents have unusually low end-of-life hospital costs. During their last six months, according to Medicare data, they spend half as many days in the hospital as the national average, and there's no sign that doctors or patients are halting care prematurely. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year.

Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.

The calm and wisdom of old age are achieved over time.

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. If end-of-life discussions were an experimental drug, the FDA would approve it.

We are all plagued by failures - by missed subtleties, overlooked knowledge, and outright errors. For the most part, we have imagined that little can be done beyond working harder and harder to catch the problems clean up after them. We are not in the habit of thinking the way the army pilots did as they looked upon their shiny new Model 299 bomber — a machine so complex no one was sure human beings could try it.

Our lives are inherently dependent on others and subject to forces and circumstances well beyond our control. Having more freedom seems better than having less. But to what end? The amount of freedom you have in your life is not the measure of the worth of your life. Just as safety is an empty and even self-defeating goal to live for, so ultimately is autonomy.

Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

Three Plagues of nursing home existence: boredom, loneliness, and helplessness.

Culture is the sum total of shared habits and expectations

elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.

At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality- the courage to seek out the truth of what is to be feared and what is to be hoped. But even more daunting is the second kind of courage - the courage to act on the truth we find.

Wilson pointed out angrily that even children are permitted to take more risks than the elderly. They at least get to have swings and jungle gyms.

A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.

There is, however, a skill to it, a developed body of professional expertise. One may not be able to fix such problems, but one can manage them. And until I visited my hospital's geriatrics clinic and saw the work that the clinicians there do, I did not fully grasp the nature of the expertise involved, or how important it could be for all of us.

To become a doctor, you spend so much time in the tunnels of preparation--head down, trying not to screw up, just going from one day to the next--that it is a shock to find yourself at the other end, with someone shaking your hand and offering you a job. But the day comes.

The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world.

You know, there's this phase of people's lives in which they can't really cope on their own, and we ought to find a way to make it manageable.

end-of-life discussions were an experimental drug, the FDA would approve it.

The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do. (...) But our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.

We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns - for both patients and society - and it can be hard to decide what do do about them.

Modernization did not demote the elderly. It demoted the family.

As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible, to keep shaping the story of their life in this world-- to make choices and sustain connections to others according to their own priorities. In modern society, we have come to assume that debility and dependence rule out such autonomy.

amount of freedom you have in your life is not the measure of the worth of your life. Just as safety is an empty and even self-defeating goal to live for, so ultimately is autonomy.