Atul Gawande Quotes

Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength. 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. Such courage is difficult enough. We have many reasons to shrink from it. But even more daunting is the second kind of courage — the courage to act on the truth we find.

assisted living isn’t really built for the sake of older people so much as for the sake of their children.

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.

THIS IS NOT, to say the least, an appealing prospect. People naturally prefer to avoid the subject of their decrepitude. There have been dozens of bestselling books on aging, but they tend to have titles such as Younger Next Year, The Fountain of Age, Ageless, or — my favorite — The Sexy Years. Still, there are costs to averting our eyes from the realities. We put off dealing with the adaptations that we need to make as a society. And we blind ourselves to the opportunities that exist to change the individual experience of aging for the better.

This is why the betrayals of body and mind that threaten to erase our character and memory remain among our most awful tortures. The battle of being mortal is the battle to maintain the integrity of one’s life — to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe their job is not to confine people’s choices, in the name of safety, but to expand them, in the name of living a worthwhile life.

fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among the patients who did sue had in fact been the victims of negligent care.

The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do.

Equally worrying, and far less recognized, medicine has been slow to confront the very changes that it has been responsible for — or to apply the knowledge we have about how to make old age better. Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010. Applications to training programs in adult primary care medicine have plummeted, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money — incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, a lot of doctors don’t like taking care of the elderly.

When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept we are not.

Tolstoy recognized this. As Ivan Ilyich’s health fades and he realizes that his time is limited, his ambition and vanity disappear. He simply wants comfort and companionship. But almost no one understands — not his family, his friends, or the stream of eminent physicians whom his wife pays to examine him. Tolstoy saw the chasm of perspective between those who have to contend with life’s fragility and those who don’t. He grasped the particular anguish of having to bear such knowledge alone. But he saw something else, as well: even when a sense of mortality reorders our desires, these desires are not impossible to satisfy. Although none of Ivan Ilyich’s family or friends or doctors grasp his needs, his servant Gerasim does. Gerasim sees that Ivan Ilyich is a suffering, frightened, and lonely man and takes pity on him, aware that someday he himself would share his master’s fate.

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”

People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.

For all but our most recent history, death was a common, ever-present possibility. It didn’t matter whether you were five or fifty. Every day was a roll of the dice.

But as your horizons contract — when you see the future ahead of you as finite and uncertain — your focus shifts to the here and now, to everyday pleasures and the people closest to you.

not only do all human beings err, but they err frequently and in predictable, patterned ways.

Medicine’s ground state is uncertainty. And wisdom — for both patients and doctors — is defined by how one copes with it.