A doctor writes about “Being Mortal”

Atul Gawande, M.D., a prominent surgeon, writer, and public health advocate, has made significant contributions to health systems innovation and safer surgery globally. In “Being Mortal,” he discusses the challenges of elderly care and end-of-life care with compassion and insight. His other books offer compelling insights into medicine and human performance.

This post was updated July 10, 2021

Atul Gawande, M.D. , author of Being Mortal, is a surgeon, writer, and public health leader. He is a practicing endocrine surgeon at Brigham and Women’s Hospital and a professor at Harvard Medical School and the Harvard T.H. Chan School of Public Health.

He founded Ariadne Labs, a joint center for health systems innovation, and Lifebox, a nonprofit organization making surgery safer globally. He also co-founded CIC Health, which operates COVID-19 testing and vaccination nationally, and served as a member of the Biden transition COVID-19 Advisory Board.

Dr. Gawande writes for The New Yorker magazine and has written four New York Times best-selling books. He won two National Magazine Awards, AcademyHealth’s Impact Award for highest research impact on healthcare, a MacArthur Fellowship, and the Lewis Thomas Award for writing about science.

In 2021 he delivered the commencement address at Stanford University , from which he had graduated. In his speech he referenced the COVID-19 pandemic, calling it the third highest cause of death in 2020. He also told the graduates,

We are often most energized when we help others express their worth.

Atul Gawande

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Being Mortal 

Medicine and What Matters in the End

In Being Mortal, Dr. Gawande explores the way most people now live, age and die and for the most part it’s not a pleasant prospect.

How we care for elderly people

As people age and lose independence due to frailness, illness, mental decline and poverty, they often also lose whatever is most important to them- their home, pets, hobbies, possessions. And these losses often occur to protect them from harm as they progress into assisted living centers, nursing homes and hospice.

Dr. Gawande describes how his  family in India expected  to care for their elderly relatives, which differed from what he saw happen when they immigrated to the United States. After becoming a physician, he recognized that our care of the elderly often robs them of the well-being that he sought to promote in his practice.

He wondered how it can be done differently. To find out, he interviewed people who are developing novel ways to provide care to older people, care that preserves their independence, dignity and choices while still keeping them safe and protected.

Most of us either have relatives or friends facing these decisions, or are facing them ourselves. If not now, we all will eventually. Whichever the case, this book shows

“how the ultimate goal is not a good death but a good life-all the way to the very end.”

Atul Gawande
woman sitting in a cemetery
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How we care for dying people

Finally, Dr. Gawande discusses end -of -life care- that is, care when a disease has become terminal and a cure is no longer likely. Sometimes it is difficult to determine when that occurs. As he says, it is rare in medicine when there truly is “nothing more we can do”.

However, just because we can do something, doesn’t mean we should. Some treatments, rather  than extending life just prolong the suffering. Still it is heart wrenching for patients and families, along with their doctors, to decide that it is time to forgo treatment and instead opt for palliative care, with or without hospice.

(Palliative care focuses on symptom management and social and emotional support for patients and families.)

Dr. Gawande poignantly describes this process by sharing in detail his  father’s cancer diagnosis, treatment, progression, hospice care and death. He shows how difficult a process this can be, given that even he and his parents, all of whom are physicians, struggled to come to terms with the reality of terminal illness and the dying process. Though they were all familiar with and experienced in dealing with the medical system, they still felt unprepared to face the decisions required at the end of life. But in the end, both he and his father felt at peace with the outcome and Dr. Gawande senior did experience “a good life-all the way to the very end.”

Other books by Dr. Gawande

Complications : A Surgeon’s Notes on an Imperfect Science

In gripping accounts of true cases, surgeon Atul Gawande explores the power and the limits of medicine, offering an unflinching view from the scalpel’s edge. Complications lays bare a science not in its idealized form but as it actually is―uncertain, perplexing, and profoundly human.

Better: A Surgeon’s Notes on Performance 

The struggle to perform well is universal: each of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives may be on the line with any decision.

Atul Gawande, the New York Times bestselling author of Complications, examines, in riveting accounts of medical failure and triumph, how success is achieved in this complex and risk-filled profession

The Checklist Manifesto:How to Get Things Right

Atul Gawande shows what the simple idea of the checklist reveals about the complexity of our lives and how we can deal with it.

Here is Dr. Gawande’s speech at the Stanford Commencement

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Effective options to control IBS, irritable bowel syndrome

The symptoms of IBS may fluctuate and even go into remission spontaneously, so it can be difficult to definitely know what works and what doesn’t. Management can be divided into two categories.

 

Even though IBS, irritable bowel syndrome, is a common gastrointestinal disorder, medical science still cannot fully explain its origin or understand the best way to treat it. But physicians can do much more to help patients with this condition than previously thought.

Here is the link to a new and updated version of this post; I suggest you go here-

This information is current as of the date of original publication or update. It may have changed by the time you read this. I invite you to fact-check what you read here.

Please do not use this information for diagnosis or treatment purposes. Before making health decisions, discuss with your physician or other qualified healthcare provider.

What is IBS?

Recurrent abdominal pain or discomfort averaging 1 day per week for 3 months associated with

  • altered bowel movements
  • change in frequency of stool
  • change in form or appearance of stool
  • not explained by other conditions that are known to cause similar symptoms

IBS patients may have any combination of pain, diarrhea, and constipation, which can alternate or go in remission at times. Other common symptoms include

  • passage of mucus
  • increased gas
  • bloating and/or fullness
a diagram of the gastrointestinal system

Physicians do not expect IBS to cause bleeding, fever, weight loss, nausea, or vomiting; such symptoms prompt investigation of other conditions, including

  • inflammatory bowel diseases-Crohn’s disease and ulcerative colitis
  • celiac disease
  • gluten sensitivity
  • lactose intolerance
  • infection
  • malabsorption syndromes

The symptoms of IBS are not unique , making diagnosis difficult since it can be confused with other conditions. Women are diagnosed with IBS more often than men, and onset of symptoms after age 50 years is unusual (although it may have been present and unrecognized. ) Children

Currently there is no one generally recognized blood test, scan, image, or other diagnostic test that confirms IBS.

Why does IBS happen?

The cause of IBS is still uncertain but gastrointestinal specialists cite several issues that likely contribute.

At one time doctors believed it was due to overactive muscles in the bowel wall, altered motility, leading to the once used name “spastic colon.” Now there are several additional factors that seem to contribute.

One pathway involves the neurotransmitters in the nerves of the bowel that transmit signals from there to the brain and back. A deficiency of these neurotransmitters may be interpreted as pain or may alter gut motility causing diarrhea or constipation.

Changes in the number and type of “gut microflora”, the bacteria that live in the bowel ,has been identified as a possible cause.

Some people develop IBS after having viral gastroenteritis (infection). The infection may trigger an intense immune response leading to chronic inflammation as the cause of the persistent symptoms.

Effective options to control IBS, Irritable Bowel Syndrome
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Managing IBS

The symptoms of IBS may fluctuate and even go into remission spontaneously, so it can be difficult to definitely know what works and what doesn’t.

Non-drug treatment options

Regular exercise, such as a daily walk, and conditioning with moderate to vigorous exercise 3-5 times a week improves digestion and encourages the bowel to move more efficiently.

Adequate and restful sleep helps manage stress that frequently precipitates symptoms.

Experts recommend changes of food choices and eating habits as basic steps to symptom control.

They emphasize eating meals at regular intervals, limited snacking, and not overeating at any time.

No one food or food group is universally off limits, but some IBS patients do well by avoiding

  • alcohol, caffeinated and/or carbonated beverages, and milk
  • spicy and fatty foods
  • gas-producing foods
  • gluten
  • artificial sweeteners
  • insoluble fiber

Some studies show a low FODMAP diet is especially helpful for bloating whether diarrhea or constipation is the major problem. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols short-chain carbohydrates (sugars) that aren’t absorbed properly in the gut.

FODMAPs are found in various  fruits, vegetables, cereals, breads, dairy, and sweeteners so it can be challenging to know what’s acceptable and what’s not. Using a list such as this one or working with a knowledgeable dietician can make it easier to find what works for you.

The Cleveland Clinic offers this FODMAP guide.

Mind based therapies

Because of the nervous system involvement,  one’s thoughts and emotions can both improve and exacerbate symptoms of IBS.  Adequately managing stress plays a key role in managing IBS symptoms.  Psychological therapies are often recommended- CBT (cognitive behavioral therapy), hypnotherapy, and psychotherapy.

 

Drug therapy for IBS

Non -prescription drugs used for IBS include

Both groups may also get help from probiotics.

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Prescription meds available in the United States specifically for IBS include linaclotide, lubiprostone, eluxadoline , rifaximin, plenecatide,and tegaserod.

Fecal Microbiota Transplantation

An interesting investigational treatment involves fecal transplantation (or bacteriotherapy) , the transfer of stool from a healthy donor into the gastrointestinal tract . Small studies have shown it effective for IBS but the effect may not be long lasting. Fecal transplantation is currently not routinely performed for reasons other than recurrent C. difficile colitis. More research studies are still needed to determine if fecal transplantation should be performed for other clinical indications. Fecal transplantation for other clinical indications should be considered experimental, and performed only as part of a research study where your safety is closely monitored.

 

What to do if you think you may have IBS

Monitor your symptoms carefully, keeping a written record, for 1-2 months. Take this to your doctor for an evaluation. However if you have these symptoms, see your doctor immediately.

  • bleeding in bowel movements
  • unexpected weight loss
  • fever
  • profuse diarrhea
  • persistent failure to pass stool
  • severe, disabling pain

A primary care doctor-a family medicine or internal medicine doctor- can evaluate these symptoms initially, and decide if referral to a GI specialist, a gastroenterologist , is needed for more specialized testing.

The American College of Gastroenterology offers these resources for patients with irritable bowel syndrome. 

 

If you have been diagnosed with IBS

Your doctor likely has already recommended some of the measure I have listed above. If not, and your symptoms are not controlled, then you might want to discuss to see if they are appropriate for you.

Remember, this is provided for your information and is not intended as advice or treatment. I  encourage you to seek care from your personal physician. 

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Dr. Aletha