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My notes on this book

"No-one pitied him as he wished to be pitied. At certain moments after prolonged suffering he wished most of all (although he would have been ashamed to confess it) for someone to pity him as a sick child is pitied. He longed to be petted and comforted. he knew he was an important functionary, that he had a beard turning grey, and that therefore what he longed for was impossible, but still he longed for it." - Tolstoy


- When a patient has a condition so bad it is certain they will die, doctors usually never acknowledge that. They don't admit it and help the patient cope with that fact. they offer no comfort or guidance, just treatments the patient could undergo.

In 1945 most deaths occurred at home, by the 1980s, just 17% did.


"The necessity of nature's final victory was expected and accepted in generations before our own. Doctors were far more willing to recognise the sings of defeat and far less arrogant about denying them." - Sherwin Nuland


- As teeth soften, the rest of our body hardens, except bones. Blood vessels, joints, the muscles in the valves of the heart, lungs pick up calcium deposits and turn stiff. The aorta of an old person can feel crunchy to the touch. At old age is it as though the calcium of our bones seeps out of our skeletons and into our tissues. To maintain the same amount of blood flow to our now narrowed blood vessels, the heart has to generate increased pressure. This is why more than half of us develop hypertension by 65. The heart becomes thicker-walled from having to pump against the pressure, and less able to respond to demands of exertion. So the peak output of the heart decreases steadily from the age of 30.

- Brains shrink. At 30 the brain barely fits inside the skull. At 70, grey matter loss leaves an inch of spare room. This is why cerebral bleeding after a blow to the head is more common. - The natural life cycle of the scalp's pigment cells is just a few years. Skin cells under the surface need to migrate and replace them. When the stem cell reservoir is used up, no more pigment is made and hair turns grey. By 50, 50% of hair is grey.

- In skin cells, the mechanisms that clear out waste products break down and those residues coalesce into a clot of gooey yellow-brown pigment: lipofuscin. Those are age spots. If lipofuscin accumulates in sweat glands, they can't function, so old age makes people very susceptible to heat.

- You always check the feet of the elderly. They may not be able to bend down and reach them, suggesting neglect and real danger. - The three primary risk factors for falling in the elderly: poor balance, taking more than four prescription medications, muscle weakness. Without these 3, they have a 12% chance of falling in a year, with all three, they have a 100% chance of falling. - A study done on 200 people over the course of their lives had them hold a pager that went of randomly 30 times a day for 20h a week, and they were asked to record their feelings at the tie. People recorded more positive feelings as they aged.

- How we seek to spend our time depends on how much time we perceive ourselves to have. When you are young and healthy, you believe you will live forever. You do not worry about losing any of your capabilities. You are willing to delay your gratification in gaining knowledge and skills for a brighter future. When horizons are measured in decades, which might as well be infinity to human beings, you most desire stuff at the top of Maslow's pyramid. But as your horizons contract - your focus shifts on the here and now, to everyday pleasures and the people closest to you.

-When life's fragility is primed, ambition and vanity disappear.

-A nursing home was filled with 100 birds, 2 dogs, 4 cats and live plants and the residents completely changed. People who never used to speak started speaking, withdrawn people started to ask to take the dog out for a walk, they gave daily reports on their birds' mood. The number of prescription drugs halved, drug costs fell by 38% and deaths fell by 15%.

- When given responsibility for a living thing, even a plant, people proved more active, more alert. People have a reason to live.

- The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until doctors tell us that there is nothing more that they can do. But rarely is there nothing more, there always is something.

- Two thirds of cancer patients reported having had no discussions with their doctors about their goals for end-of-life care, despite being on average, just four months from death. But the third who did were far less likely to undergo cardio-pulmonary resuscitation or be put on a ventilator or end up in an ICU. They suffered less, were physically more capable for a longer period. 6 months after they died their family members were markedly less likely to experience persistent major depression.

- A mistake made by doctors when discussing terminal illness: they want to determine what people want as their primary goal. If they want chemotherapy or not, if they want to be resuscitated or not, hospice care or not. Focus is put on the facts and the options But a large part of the task is helping people negotiate overwhelming anxiety - about death, suffering, loved ones, finances. They are many worries and real terrors. No one conversation can address them all. It is a process, not an epiphany to accept ones mortality, and the limits and possibilities of medicine.

- And so you sit down, you make time. You're not determining whether they want treatment X versus Y. You're trying to learn what is the most important thing to them under the circumstances, so you can give them information and advice on the approach that gives them the best chance of achieving it: As much listening as talking

- You shouldn't say "I'm sorry that things turned out this way." you are distancing yourself. Rather "I wish things were different."

- Not "What do you want when you are dying?" but "If time becomes short, what is most important to you?"

- You ask what they understand their prognosis to be. What are their concerns about what lies ahead. What kind of trade-offs are they willing to make. How do they want to spend their time if their health gets worse. Who do they want to make decisions if they can't.

"We pay doctors to give chemotherapy and to do surgery but not to take the time required to sort out when to do so is unwise." - Atul Gawande

- In a war that you cannot win, you do not want a general who fights to annihilation




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