Being Mortal: Medicine and What
Matters in the End
Atul Gawande
Henry Holt and Company
2014
New York
Dr. Atul Gawande is a model writer
of non-fiction, a game-changing analyst of the medical scene, and an honest and
appealing narrator. In his fourth book, he details his investigations and
experiences in the land medicine can’t touch – mortality and death.
With a huge bulge of 64 million
Baby Boomers (myself included) in America destined for geriatric status and
death in the next few decades, a corresponding upswing in interest in
end-of-life decision-making, death, and what was known as ars moriendi, the art of dying, is taking place. This movement is
beginning to counter a long-standing cultural abhorrence of aging and death,
and the decades-long relocation of the elderly and the dying from the home to
medical facilities.
“Being Mortal” is the most
effective examination of the problem I have read to date. Gawande explores the
problems and frustrations of a system that institutionalizes the elderly,
because it has no viable alternative mandate. Gawande illustrates his
conclusions with several threads of narrative – persons failing and succeeding
at achieving a “good death,” and includes his own story, of his father’s
passing, in clear-eyed but heart-rending detail.
Along the way, we are given
illuminating historical context. Modern medicine’s life-saving technologies made
the hospital the logical destination for the dying in the 20th Century
(most people died at home until after World War I). However, by 1954, the
chronically ill and elderly were taking up all the hospital beds, and “custodial
units” were created by mandate. These morphed into nursing homes.
For those of us who remember some
of the places in which our ancestors and relatives were warehoused, the idea
that no real planning went into their creation is transparent. Additionally,
the resources and knowledge to help the aging simply doesn’t exist.
“I asked Chad Boult,
the geriatrics professor, what could be done to ensure that there are enough
geriatricians for the surging elderly population. ‘Nothing,’ he said. ‘It’s too
late.’”
But Gawande is not content to
bemoan the state of things. First, he cites the stories of many innovators who
bucked the system to create new living systems and concepts that provide the
elderly with purpose, choice, community, information, and autonomy. People such
as Bill Thomas and Keren Wilson, and places such as NewBridge on the Charles
and Peter Sanborn Place, and groups such as Eden Alternative and Beacon Hill
Villages, all of whom/which have developed viable alternatives that actually
extend participants’ lives, improve their heath and sense of well-being, and,
ironically, cost less to boot. (He even includes Chad Boult’s solution to the
dearth of geriatricians – have them train all doctors and nurses in elderly
care!)
These aren’t theories. They are
proven methods, spelled out in a practical and they radiate out from the
central concern of humanizing the medical process. Gawande neatly summarizes
the medical profession’s aversion to acknowledging death – to it, death
signifies failure. He outlines his own painful lack of experience in discussing
unavoidable death, or the more excruciating task of helping patients evaluate
when to stop requesting medical procedures that might prolong life, but at a
debilitating and painful cost.
He comes up with essential questions: “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?” (Again, cited studies in the text demonstrate that discussing
the inevitable improves health and prolongs life.)
Despite the plethora of proactive benefits to be reaped from
reading “Being Mortal,” the real pain and dismay of families forced to face an
impending loss, the agonizing change of dynamics as the children become
caregivers for parents, is not avoided or minimalized. However, in contrast to
much of the challenging material I plow through in my efforts to understand and
communicate on this subject, here is sense of hope and achievable positive
change.
And in the broadest sense the book reminds me that the
elements enumerated as essential to quality of life at its end is equally valid
for all ages. “Human beings . . . have a need for both privacy and community,
for flexible daily rhythms and patterns, and for the possibility of forming
caring relationships with those around them.” At the end at always, we need not
just safety and protection, but worth and freedom, meaning and purpose, what
Gawande calls “shaping our stories,” within the limitations imposed by our
bodies and the dimensions of human life.
The perils and possibilities are still there, but “Being Mortal”
gives us some tools with which to work.