When a person turns sixty-five it is supposed to be a major demarcation in one’s life. Since that milestone will achieved next Monday I guess I have entered a new realm and should begin thinking about my own mortality. For Christmas my son-in-law, Jonathan, asked me to give him a copy of Atul Gawande’s book, BEING MORTAL: MEDICINE AND WHAT MATTERS IN THE END. Being the dutiful father-in-law and a self-confessed bookaholic I readily complied. I read the dust jacket and thought at some point I should read Gawande’s work. Further, my wife and I spent a few weeks in Cabo in January and met a number of our friends, two of whom, David and Monty are physicians and they raved about the book and how it provoked them to reexamine the approach they had taken in dealing with patients throughout their long and successful careers. As a result, the time has arrived and I felt that part of my catharsis of being eligible for Medicare would be spent with Dr. Gawande. I must say I could not put the book down and it opened my eyes to many things that I really had not thought about pertaining to my own, and my wife Ronni’s mortality.
From the start Gawande points out that most doctors are not trained to deal with end of life issues and decisions that people must make. Doctors really do not know how to talk to people dealing with their mortality and how they can help them. Gawande asks many important questions in his work. Probably the most important deals with whether the solutions doctors offer the terminally ill will enhance their last days, or will they make their situations worse. Medicine is designed to solve problems and nothing is more threatening to a clinician than confronting a problem they cannot solve. Offering a patient a myriad of options ranging from surgery, chemotherapy, radiation, drugs etc. in far too many cases detracts from a person’s end of life experience, than actually helps them. Gawande states that his book is “about the modern experience of mortality-about what it’s like to be creatures who age and die, how medicine has changed the experience and how it hasn’t, where our ideas about how to deal with our finitude have got the reality wrong…..Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.”(9)
Gawande’s work addresses his theme in a meaningful, honest, and sensitive fashion. He integrates numerous interviews with patients and practitioners to form a marvelous narrative that readers can understand and relate to. He includes the personal stories of his wife’s grandmother and his own father as he tried to cope with how best to facilitate their end of life experience. With these and numerous case studies he presents, he himself is educated by palliative nurses and physicians on what questions patients should be asked and how they should be approached. The key question lies in the patient’s phenomenological world; how do they feel? What do they expect from their remaining time, and most importantly how much medical intervention do they want to put up with in terms of the quality of life they hope to enjoy as time draws to a close?
One of the key components as to a patients quality of life toward the end is where they want to be, a hospital, under hospice care, assisted living, nursing home, or in their own homes. Gawande explores all of these options describing real people and the decisions they and their families have to make. In 1790 only 2% of people lived to be over sixty-five, today that figure is about 20%. As the post war baby boom generation comes of age that figure will dramatically increase. But has society adapted to the new demographic problem it is now facing? The answer is a resounding no! We now have fewer and fewer geriatric physicians at a time when they are desperately needed. Is aging a medical problem? For most doctors it isn’t, but for a geriatrician it is. People cannot stop their bodies from aging, but there are ways to make it more manageable and avert some of its worst affects.
The author does an excellent job integrating aspects of the history of medicine into his narrative providing the reader the context for the points he is trying to develop. Issues of institutionalization, dependency, and many others are thought provoking for a society that tries not to deal with the final phase of life. How to make life worth living when we are weak and frail and can’t fend for ourselves anymore should be something that doctors and their elderly patients should confront together from the perspective that Gawande introduces. Another important question remains; “what makes life worth living when we are old and frail and unable to care for ourselves?”(92) Do we want safety or happiness? Happiness for the elderly is mostly centered on self-sufficiency and how do you maintain the joy of life for the infirm? Gawande’s approach addresses these concerns in a very positive manner. He freely admits his own inadequacies in this area, but he tries to explore and develop solutions that center around the dignity of those facing death in the near future.
For Gawande, people want to be the authors of their own lives and he believes that society has finally entered an era that the medical community is starting to believe “that their job is not to confine people’s choices, in the name of safety, but to expand them, in the name of worthwhile life.”(141) Perhaps the most profound statement in the book is “you live longer only when you stop trying to live longer.”(178) The greatest failure in how we treat the sick and 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.”(243) Gawande closes by reiterating that medicine can do a great deal of damage when we fail to acknowledge that such power is finite and will always be.
BEING MORTAL is a powerful book that seniors, their families, physicians, and members of Congress should have as required reading. It will provide insights into one of the most important health issues we face today.