Agent death

Summary

Being Mortal

The independent self

• The development of the nuclear family required that one child remained at home to care for their parents. 
  
• Living into old age has become more common.  
• Increased longevity means that parents compete for resources, such as the family home, with their offspring resulting in tensions between the generations. 
  

Things fall apart

• Teeth get difficult to clean because the decay is not felt as easily, and the aged person struggles to use the tooth brush and floss. 
  
• Teeth and bones soften as calcium ions leach from them and flow into the soft tissues where they make the rest of the body harden.  
• The hardening of arteries forces the heart to pump harder. 
  
• Lose bone and muscle mass. 
  
• Brain shrinks (initially the frontal lobes of the cerebral cortex is at the front of the brain.  It includes the: prefrontal cortex, motor cortex.  Sapolsky asserts it makes you do the harder thing when it's the right thing to do.  The frontal cortex supports working memory to sustain focus on a task.  It also coordinates the strategic actions necessary to achieve success.  It provides impulse control, regulation of emotion, and willpower.  The prefrontal cortex maintains focus by deprioritizing currently irrelevant streams of information.  The frontal cortex tracks rules.  Over a lifetime, that builds into a costly activity.  Once it tires, responses become less prosocial.  But practice shifts operation of tasks to the cerebellum.  The frontal cortex signals the tegmentum and accumbens with the conclusions of its expectancy/discrepancy calculations.  The frontal lobe provides executive function, considering bits of information, assessing patterns and then prioritizing the strategies.  The frontal lobe is the most recent part of the brain to evolve and involves a disproportionate percentage of primate-unique genes in its development and operation.  It does not complete development until the mid-20s.  It includes spindle neurons.  It is easily damaged.  Sapolsky (Nauta) notes that its ventromedial prefrontal cortex is a quasi-member of the limbic system. 
  and hippocampus is a part of the medial temporal lobe of the brain involved in the temporary storage or coding of long-term episodic memory.  It includes the dentate gyrus.  Memory formation in the cells of the hippocampus uses the MAP kinase signalling network which is impacted by sleep deprivation.  The hippocampus dependent memory system is directly affected by cholinergic changes throughout the wake-sleep cycle.  Increased acetylcholine during REM sleep promotes information attained during wakefulness to be stored in the hippocampus by suppressing previous excitatory connections while facilitating encoding without interference from previously stored information.  During slow-wave sleep low levels of acetylcholine cause the release of the suppression and allow for spontaneous recovery of hippocampal neurons resulting in memory consolidation.  It was initially associated with memory formation by McGill University's Dr. Brenda Milner, via studies of 'HM' Henry Molaison, whose medial temporal lobes had been surgically destroyed leaving him unable to create new explicit memories.  The size of neurons' dendritic trees expands and contracts over a female rat's ovulatory cycle, with the peak in size and cognitive skills at the estrogen high point.  Adult neurogenesis occurs in the hippocampus (3% of neurons are replaced each month) where the new neurons integrate into preexisting circuits.  It is enhanced by learning, exercise, estrogen, antidepressants, environmental enrichment, and brain injury and inhibited by various stressors explains Sapolsky.  Prolonged stress makes the hippocampus atrophy.  He notes the new neurons are essential for integrating new information into preexisting schemas -- learning that two things you thought were the same are actually different.  Specific cells within the hippocampus and its gateway, the entorhinal cortex, are compromised by Alzheimer's disease.  It directly signals area 25. 
  ).  This is often seen as multi-tasking capabilities peaking in mid-life.  Once brain has shrunk the skull becomes less protective since the brain rattles about inside. 
  

1. Genetically organized shutdown. 
   
2. Gawande notes that until recently we died on average before 30 so he doubts that aging is normal.  So he sees wear and tear as likely culprits.  He cites Leonid Gavrilov who claims that all complex systems fail randomly and gradually because they leverage redundancy.  But over
   Carlo Rovelli resolves the paradox of time. 
   Rovelli initially explains that low level physics does not include time:
   

   • A present that is common throughout the universe does not exist
     
   • Events are only partially ordered.  The present is localized
   • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
   • Time passes at different speeds dependent on where we are and how fast we travel
     
   • Time's rhythms are due to the gravitational field
     
   • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
     
   • Fundamentally there is no time.  The basic equations evolve together with events, not things 

   Then he explains how in a physical world without time its perception can emerge:
   

   • Our familiar time emerges
     
   • Our interaction with the world is partial, blurred, quantum indeterminate
     
   • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
   • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
     
   • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
     
   • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

   
   
   time the backup systems fail too resulting in frailty and eventual collapse.  Felix Silverstone a senior geriatrician at Parker Jewish Institute NY agrees.  He does not see a single common cellular mechanism.  Instead we just fall apart.  

• People are still retiring at 65 creating a huge overhead. 
• The number of geriatricians is falling.  It is not well reimbursed by Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS.  Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage.  It includes:
  
  • Benefits
  • Part A: Hospital inpatient insurance.  As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization.  Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital. 
    
  • Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
    
  • Part C: Medicare Advantage 
  • Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices. 
    
  • Eligibility
    
  • All persons 65 years of age or older who are legal residents for at least 5 years.  If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived.  Medicare is legislated to become the primary health plan. 
    
  • Persons under 65 with disabilities who receive SSDI. 
    
  • Persons with specific medical conditions:
  • Have end stage renal disease or need a kidney transplant. 
    
  • They have ALS. 
    
  • Some beneficiaries are dual eligible. 
    
  • Part A requires the person has been admitted as an inpatient at a hospital.  This is constrained by a rule that they stay for three days after admission.  
    
  • Sign-up
  • Part A has automatic sign-up if the person is drawing social security.  Otherwise the person must sign-up for Part A and Part B. 
    
  • Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office.  But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July.  Incremental yearly 10% penalties apply for not signing up at 65.  These penalties apply to all subsequent premiums. 
    
  • Premiums
  • Part A premium
  • Part B insurance premium
    
  • Part C & D premiums are set by the commercial insurer.  
  and so medical schools are turning out highly remunerated oncologists, orthopedic surgeons, urologists is a surgical and medical specialty which deals with diseases of the male and female urinary tract and the male reproductive organs. 
  etc.  Also there are few tools to support doing geriatrics well and the complex diseases encountered are hard to handle.  But that is a pity.  Patients supported by a geriatrics team had 25% less likelihood of becoming disabled, were half as likely to develop depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events.  There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide.  Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time.  There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015).  The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure.  Michael Pollan concludes depression is fear of the past.  It affects 12% of men and 20% of women.  It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016).  Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression.  Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease.   It has been associated with an aging related B12 deficiency (Sep 2016).  During depression, stress mediates inhibition of dopamine signalling.  Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC.  There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC.  Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression.  Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable.  Sufferers of mild autism often develop depression.  Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25.  Drug treatments are required for cases with above average activity of the right anterior insula.  As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony.  By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress.   Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; and were 40% less likely to require home help.  They obtained these results by:
• Simplifying medications
• Avoiding isolation
• They controlled arthritis
  
• They ensured the patients ate three square meals a day.  But none of these strategies is sexy and Medicare did not cover the costs.  Medical centers have consequently closed their geriatrics departments.  
• Gawande suggests it is too late in the US is the United States of America.   to reverse the trend.  But it would still be possible for the current geriatricians to teach PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
  s their skills. 
  

• Check feet since if they are in poor condition it signals that the person is not able to care for them. 
  
• Check agility of the patient in getting onto the exam table.  Loss of agility typically correlates with increased falling.  Falling is the key danger:
• 40% of falls drive the person into a nursing home. 
  
• 20% never walk again. 
  
• The risk factors are poor balance, muscle weakness and more than four medicines.  There is a 10% chance of falling without one of these factors.  With all three its 100%.  
• Medicines may include a diuretic.  As people age these become problematic causing dehydration leading to dizziness.  Geriatricians can hugely reduce the risks by thoughtfully adjusting the medicines to be age appropriate.  
• Old people tend to eat too few calories.  This contributes to muscle weakness. 
  
• They aim to help their patients to:
  
• Gain as much freedom from the ravages of disease as possible.  
• Retain enough function for active engagement in the world.  This is an unusual goal for most doctors.  

Dependence

• Household possessions
• Transport independence
• Personalized and interesting meals
• Own control of activities.  Many institutions organize group activities which are not valued by the residents.  

Assistance

• Parent and child trade roles
• Parent no longer master of his house
  
• Parent moves away from old friends and communities

• Parents often adapt to the situation by befriending visitors
• Caregiver (daughter) has little help but a demanding role and becomes more constrained:
• Coping with falls
• Woken by parents nightmares
• Having to upgrade infrastructure
• Handling prostrate issues
• Having to provide different menus for parent and family
• Managing the trips to specialists
• Finds job impacted

• It is difficult to do. 
  
• Caregivers have to think and act differently.  They have to be less efficient and more attentive. 
• Children of the elderly are interested in their parents' safety. 
  
• Parents allow their children to make the choices. 
  

A better life

• Plants - vegetable garden and plants. 
  
• Animals - Dogs, cats and 100 birds. 
  
• Children.  

• Residents began to wake up and come to life
• People who were considered incapable of speech started speaking. 
  
• People who had been completely withdrawn and non-ambulatory started walking the dogs. 
  
• Residents named the birds. 
  
• The number of prescriptions per resident halved.  Psychotropic drug need fell more.  Deaths fell by 15% 
  

• It has all single rooms - a typical issue for residents of regular nursing homes. 
  
• Caregivers are given control of their schedule.  They are encouraged to be focused on just a few residents and to do the cooking, cleaning, helping and friending.  
  

• It had to individually intervene with local hospitals and ambulance services who otherwise pushed the residents they treated into traditional long term care facilities. 
  
• It had residents replace PCP is a Primary Care Physician.  PCPs are viewed by legislators and regulators as central to the effective management of care.  When coordinated care had worked the PCP is a key participant.  In most successful cases they are central.  In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements.  Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments. 
  s who would not accept their unconventional model of care.  

Letting go

• Year 1 $28,000 for diagnostics, surgery, radiation and chemotherapy is the treatment of cancers by highly cytotoxic chemicals: Paclitaxel, Platinum, 6-mercaptopurine; assuming that cancer cells are unusually active and will be differentially poisoned.  It has been successful in offering treatments when no other course was available, but non-specificity means that healthy cells also get poisoned resulting in side effects which increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%). 
  . 
  
• Year 2 .. n -1 $2000 a year
• Year n $94,000 for metastatic breast cancer is a variety of different cancerous conditions of the breast tissue.  World wide it is the leading type of cancer in women and is 100 times more common in women than men.  260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths.  The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS.  Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-.  Metastasis classes the cancer as stage 4.  Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2.  Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013).  International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018). 
  

• Avoid suffering
• Strengthening relationships with family and friends
• Being mentally aware
• Not being a burden on others
• Achieving a sense that their life is complete

• Advanced cancer
• Dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect.  The most common form for people under 60 is FTD.  Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru.  The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system.  It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training.  Dementia appears to develop faster in women than men.  
• Parkinson's disease corresponds to the breakdown of certain interneurons in the brain.  It is not fully understood why this occurs.  Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity.  In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease.  In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons.  But poisoning from MPTP has also been shown to destroy dopamine system neurons.  DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus.  People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease.  The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome.  This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain.  Paraquat has also been linked to Parkinson's disease.  Parkinson's disease does not directly kill many sufferers.  But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food.  And it undermines balance which can increase the possibility of falls.  Dememtia can also develop.  Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients. 
  
• Progressive organ failure: heart > lungs/kidneys provides multiple vital functions.  It: Produces renin which supports negative feedback, Removes excess organic molecules from the blood, Regulates electrolytes in the blood, Maintains pH homeostasis, Regulates fluid balance, Regulates blood pressure, monitors blood oxygen concentration and signals erythropoiesis with EPO, Reabsorbs water, glucose (SGLT2) and amino acids.  Kidney function is monitored with the GFR.  Kidneys can fail acutely or chronically.  Kidneys are affected by a variety of cancers including: advanced kidney cancer, von Hippel Landau; some of which are induced by PFAS.    Multiple myeloma, type 2 diabetes, TB and drug treatments for MDR TB place a strain on the kidneys and can induce failure.   > liver is an emergent cellular system providing metabolic: Dietary compound metabolism and signalling: After gorging on sugar-rich foods the liver releases FGF21 hormone to dampen further eating activity; Detoxification, Regulation of glucose through glycogen storage (asprosin signalling from white adipose tissue); clotting, immune, exocrine and endocrine functions.  It is supplied with oxygen-rich blood via the hepatic artery and blood rich in semi-processed foodstuffs from the intestines & spleen via the hepatic portal vein.  It is constructed from: Hepatocytes which swim in the blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood vessels.  The embryonic endoderm cells invade the mesoderm to form the liver bud.  Subsequently the liver bud vascularizes and is colonized by hematopoietic cells.  The liver operates on a daily cycle (Aug 2018) allowing it time to recover from the stress of processing toxic substances.  In a healthy adult liver cells do not divide significantly.  But in a damaged liver, the liver cells shift back to a neonatal state to re-enter the cell cycle and rebuild the liver.  There are over 100 disorders of the liver.  Obesity and diabetes are associated with increased prevalence of these liver disorders worldwide. 
  .  
• Old age

• Are you in pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems.  But feeling pain is supported by older biological functions that support homeostasis.  These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems.  Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'.  Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers.  A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex.  The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks.  Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so.  Fear of pain is a significant contributor to female anxiety.  Pain is the main reason people visit the ED in the US.  Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation. 
  ?
• How is your appetite, thirst, sleeping?
• Any trouble with confusion, anxiety is manifested in the amygdala mediating inhibition of dopamine rewards.  Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias.  Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density.  Some estrogen receptor variants are associated with anxiety in women.  Women are four times more likely to suffer from anxiety.  Louann Brizendine concludes this helps prepare mothers, so they are ready to protect their children.  Michael Pollan concludes anxiety is fear of the future.  Sufferers of mild autism often develop anxiety disorders.  Treatments for anxiety differ.  50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac).  Cognitive anxiety (extreme for worries and anxious thoughts) is also helped by yoga.  But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT.  Tara Brach notes that genuine freedom from fear is enabled by taking refuge. 
  or restlessness?
• Chest pain or heart palpitations?
  
• Trouble with constipation, urination or walking?
• Checks if taking medicines
  

• Morphine for pain
• Ativan for anxiety
• Compazine for nausea
• Haldol for delirium
• Tylenol for fever
• Atropine for death rattle

Hard conversations

1. 'Dr. knows best' enforces a treatment plan that moves the patient to the ICU is intensive care unit.  It is now being realized that the procedures and environment of the ICU is highly stressful for the patients.  In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD.  Intubation and catheterization are also traumatic.  Sometimes seperated into MICU and SICU.  eICU skill centralization may bring down costs. 
   .  
2. 'Dr. informative' who presents details of treatments and their statistical effects.  This approach leaves the patient anxious and bewildered but also heading towards the ICU. 
   
3. 'Dr. complexity' who:
• Asks questions to identify the patients goals and fears
• Takes
  Carlo Rovelli resolves the paradox of time. 
  Rovelli initially explains that low level physics does not include time:
  

  • A present that is common throughout the universe does not exist
    
  • Events are only partially ordered.  The present is localized
  • The difference between past and future is not foundational.  It occurs because of state that through our blurring appears particular to us
  • Time passes at different speeds dependent on where we are and how fast we travel
    
  • Time's rhythms are due to the gravitational field
    
  • Our quantized physics shows neither space nor time, just processes transforming physical variables. 
    
  • Fundamentally there is no time.  The basic equations evolve together with events, not things 

  Then he explains how in a physical world without time its perception can emerge:
  

  • Our familiar time emerges
    
  • Our interaction with the world is partial, blurred, quantum indeterminate
    
  • The ignorance determines the existence of thermal time and entropy that quantifies our uncertainty
  • Directionality of time is real but perspectival.  The entropy of the world in relation to us increases with our thermal time.  The growth of entropy distinguishes past from future: resulting in traces and memories
    
  • Each human is a unified being because: we reflect the world, we formed an image of a unified entity by interacting with our kind, and because of the perspective of memory
    
  • The variable time: is one of the variables of the gravitational field.  With our scale we don't register quantum fluctuations, making space-time appear determined.  At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions

  
  
  time to slowly adjust as the patient adapts. 
  
• Aligns strategic options with the goals and fears identified earlier. 
  
• Agrees a plan with the patient.  Gawande stresses this is not just a set of options which would result in inducing panic.  Instead treatments are described with benefits of success and risks and impacts.  And alternative palliative aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis.  /hospice options are evaluated.  The situation must cope with adaption.  At each point Gawande stresses it is important to ask the patient:
• What goals are important?
• What tradeoffs are they willing to make?

Courage

1. To confront reality of our mortality -- the courage to seek out the truth of what is to be feared and what is to be hoped
   
2. To act on the truth we find

1. Should not be allowed for healthy people who are likely to reevaluate their situation in the future. 
   
2. Presents a valuable option for the terminally ill who are suffering.  But Gawande notes in societies where it has been deployed it tends to undermine the development of hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now.  There are major hospice chains focused on providing palliative care. 
   type strategies that could reduce the suffering and allow the patient to achieve more of their immediate goals.  

Epilogue

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