终于下定决心把这本书听完了。知道这么书已经有一阵了，但是一直都不能下定决心。昨天带着Rixi在公园里走路的时候，秋风吹过来，我们踩着落叶，清脆的声音在耳边响起，耳朵里是作者的叙述，那个时候觉得都不知道自己在哪里。应该是做决定的时候了。
医学，医治是有绝对的局限性的。这一点对老人和病衰之人来说尤为如此。作者一直想强调的是，不是说我们要去讨论怎么好好地去死，而是讨论怎么好好地活到死亡来临。最为艰难但是又是必须要去做的，则是在那之前的谈话，你究竟想要什么，如果你为了这个想要的，愿意做多大的妥协。作者用了大量的例子来阐明如何过好你生命的最后一个阶段对将逝去的人和他/她周围的人将会是多么重要。
Chapter 5
Making lives meaningful in old age is new. Is therefore requires more imagination and invention than making them merely safe does.
There are people in the world who change imaginations. You can find them in the most unespected places. And right now, in the seemingly sleepy and mundane precincts of housing for the elderly, they are cropping up all over.
.. believe that you didnot need to sacrifice your autonomy just because you needed help in your life. And I realized, in meeting these people, that they shared a very particular philosophical idea of what kind of autonomy mattered most in life.
There are difference concepts of autonomy. One is autonomy as free action - living completely independently, free of coercion and limitation. This kind of freedom is a common battle cry. But it is, a fantasy. 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
All we ask is to be allowed to remain the writers of our own story. That story is ever changing. Over the course of our lives, we may encounter unimaginable difficulties. Our concerns and desires may shift. But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties.
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 how 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 o 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.
The terror of sickness and old age is not merely the terror of the losses one is forced to endure but also the terror of the isolation. 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 the 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. What I learned from Lou - and lots of others - was that it is very much possible.
Chapter 7
there are two types of doctor: one is the paternalistic doctor: surgery was the best choice;
the 2nd is the informative doctor: here is the red pill and here is the blue pill. It's up to you to choose. This is the increasingly common way for doctors to be, and it tends to drive us to become ever more specialized. We know less and less about our patients but more and more about our our science. Overall, this kind of relationship can work beautiful, especially when the choices are clear, the trade-offs are straightforward, and the people have clear preferences. You get only the test, the pills, the operations, the risks that you want and accept. You have complete autonomy.
We want information and control, but we also want guidance.
3rd type: interpretive.
What is most important to you?
What are your worries?
THE CHOICES DON'T stop, however, life is choices, and they are relentless. No sooner have you made one choice than another is upon you.
Chapter 8
Why was the choice so agonizing? The choice, I realized, was far more complicated than a risk calculation. For how do you weigh relief from nausea, and the chances of being able to eat again, against the possibilities of pain, of infections, of having to live with stooling into a bag?
The brain gives us two ways to evaluate experiences like suffering - there is how we apprehend such experiences in the moment and how we look at them afterwards - and the two ways are deeply contradictory.
People seemed to have two different selves - an experiencing self who endures every moment equally and a remembering self who gives almost all the weight of judgement afterward to two single points in times, the worse moment and the last one. The remembering self seems to stick to the Peak-end rule even when the ending is an anomaly.
If the remembering self and the xperiencing self can come to radically difference opinions about the same experience, then the difficult question is which one to listen to.
In the end, people don't view their life as merely the average of all of its moments - which after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurement of people's minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life may be empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves. Unlike your experiencing self - which is absorbed in the moment - your remembering self is attempting to recognize not only the peaks of job and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. And in stories, ending matter.
Yet we also recognize that the experiencing self should not be ignored. The peak and the ending are not the only things that count. In favoring the moment of intense joy over steady happiness, the remembering self is hardly always wise.
"An inconsistency is built into the design of our minds," Kahneman observes. "We have strong preferences about the duration of our experiences of pain and pleasure. We want pain to be brief and pleasure to last. But our memory... has evolved to represent the most intense moment t of an episode of pain or pleasure (the peak）and the feelings when the episode was at its end. A memory that neglects duration will not serve our preference for long pleasure and short pains."
When our tie is limited and we are uncertain about how best to serve our priorities, we are forced to deal with the fact that both the experiencing self and the remembering self matter. We do not want to endure long pain and short pleasure. Yet certain pleasures can make enduring suffering worthwhile. The peaks are important, and so is the ending.
If she could be freed from what he rumor was doing to her to enjoy just a few more such experiences with the people she loved - she would be willing to endure a lot. On the other hand, she didn't want to chance a result even worse than the one she already faced with her intestines cinched shut and fluid filling her abdomen like a dripping faucet.
Courage is the strength to recognize both realities. We have room to act, to shape our stories, though as time goes on it is within narrower and narrower confines. A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one's story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone's lives.
Inevitably, the question arises of how far those possibilities should extend at the very end - whether the logic of sustaining people's autonomy and control requires helping them to accelerate their own demise when they wish to.
At root, the debate is about what mistakes we fear most - the mistake of prolonging suffering or the mistake of shortening valued life. We stop the healthy from committing suicide because we recognize that their psychic suffering is often temporary. We believe that, with help, the remembering self will alter see matters differently he experiencing self - and indeed only a minority of people saved from suicide make a repeated attempt; the vast majority eventually report being glad to be alive. But for the terminally ill who face suffering that we know will increase, only the stonehearted can by unsympathetic.
All the same, I fear what happens when we expand the terrain of medical practice to include actively assisting people with speeding their death. I am less worried about abuse of these power than I am about dependence on them. Proponents have crated the authority to be tightly circumscribed to avoid error and misuse.
Certainly, suffering at the end of life is sometimes unavoidable and unbearable, and helping people end their misery may be necessary.
Epilogue
Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor.
We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Tose reasons matter not just at th end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: what is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?
The field of palliative care is advancing, which causes for encouragement, not cause for celebration. That will be warranted only when all clinicians apply such thinking to every person they touch. No separate specialty required.
Sometimes we offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the large aims of a person's life.
I also saw how to come to terms with limits that couldn't siply be wished away. When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that there are times when the cost of pushing exceeds its value. Helping my father through the struggle to define that moment was simultaneously among the most painful and most privileged experiences of my life.
Part of the way my father handled the limits he faced was by looking at them without illusion. Though his circumstances sometimes got him down, he never pretended they were better than they were. He always understood that life is short and one's place in the world is small. But he also saw himself as a link in a chain of history. Floating on that swollen river,
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