This month marks ten years since my initial diagnosis of multiple myeloma. The more days, months, and years between then and now, the farther out I am on the branch of mortality. As I told my friend Larry, who was diagnosed with myeloma 13 years ago, we’re both at the point we can hear that branch creaking and threatening to crack.

What an excellent time to read Atul Gawande’s new book, Being Mortal.

Being Mortal is getting a lot of favorable attention, and for good reason. Gawande, a surgeon and medical writer, squarely tackles the disconnect between modern medicine and death. And let’s face it: death is not a topic many doctors are comfortable with discussing. My own oncologist of a decade, with whom I have a wonderful relationship, is distinctly un­com­fortable when I have raised the topic of dying. He doesn’t want to have that conversation and prefers to focus instead on all the treatments I haven’t tried yet.

Even Gawande acknowledges that he was well into his medical career before he learned to have “the hard conversation.” Eventually, working with palliative specialists and hospice workers, he came up with a short series of questions to ask his patients:

• What is your understanding of what is happening to you (medically, physically)?
• What are your biggest fears and concerns about what is happening?
• What goals are most important to you?
• What trade-offs are you willing to make or not willing to make?

Those are questions my oncologist has yet to ask me. I am not waiting for him to do so. I need to start an­swer­ing those questions for my own sense of where I am going with this disease.

I have already scribbled out some lines. I am not willing to undergo a stem cell transplant again. I am not will­ing to try Velcade ^[1] (bortezomib) again in any form. And while I have not yet had to put this one to the test, at some point I am unwilling to continue treatment. Period. I do not want to become a patient for whom there is no quality of life as I define quality of life. I do not want to continue a treatment that will beat me down while keep­ing me “alive,” but not add meaningfully or significantly to my lifespan.

Recently, the media paid a great deal of attention to Brittany Maynard, the young woman with a terminal brain tumor who chose a physician-assisted death as her disease advanced. Whether you agree with physician-assisted death, Maynard’s very public story brought new attention to the topic of death with dignity. Gawande is reluctant to embrace fully physician-assisted death, but he is very much a proponent of achieving a dig­ni­fied death through other means. And he clearly articulates why and how the modern medical jugger­naut may thwart that outcome.

One passage in Being Mortal describes in harsh but moving terms where I am at in my disease:

People with incurable cancers … can do remarkably well for long time after diagnosis. They undergo treatment. They resume regular life. They don’t feel sick. But the disease, while slowed, continues pro­gressing, like a night brigade taking out perimeter defenses.

Those lines brought my reading to a halt until I could breathe again and move forward. I know that night brigade has been working slowly, stealthily for a decade.

I also know that in the end, we all die. My having myeloma just means I am dying faster than I’d counted on in those pre-myeloma days a decade ago.

My goal is not to pretend I am not dying faster, but instead to look ahead – whether it is a year or another ten years – and know that I am making the decisions I need and want to make to bring this amazing experiment called life to its conclusion.