Being Mortal: Medicine and What Matters in the End
By Atul Gawande, Published by the Penguin Group (2014)
Reviewed by John E. Wade II
I highly recommend this practical, informative, and no-holes-barred book to everyone, from middle age to those who are grappling with the potential ending stages, which may include everything from life support systems to assisted living to nursing homes. Many can also be enlightened by Dr. Gawande’s book, as it is wonderful for thoughtful people who seek to understand life. Dr. Gawande is the author of three best-selling books and a doctor; his parents were both also doctors.
Gawande tells the touching stories of his own patients as well as his father, as he progressed and eventually died. Tears came to my eyes at the passing of Gawande’s father. Personal stories are woven around surprising facts, such as the one about his medical school: “Our textbooks had almost nothing on aging or frailty or dying. Yet, death, of course, is not a failure. Death is normal.”
Gawande spoke of his Indian grandfather, whom his family held in high regard, as was the custom. “He emphasized education, hard work, frugality, earning your own way, staying true to your word, and holding others strictly accountable for doing the same.” By contrast, now people tend to understate their age to census takers while in prior censuses people overstated it.
With all of our current-day problems, Gawande states, “There arguably is no better time in history to be old.” He makes an interesting statement, “The veneration of the elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.”
Life used to be short and medicine of little help. “Over the years, the advent of sanitation and other public health measures sharply replaced the likelihood of death from infections, disease, especially in early childhood; and clinical advances dramatically reduced the mortality of childbirth and traumatic injuries.”
As time went on, “The progress of medicine and public health has been an incredible boom—people get to live longer, healthier and more productive lives than ever before.”
But death is still there. Gawande states, “. . . for most of our hundred-thousand year existence—all but the past couple of hundred years—the average life span of human beings has been thirty years or less . . .” So, today, with our average life span in much of the world climbing past eighty years, “we are already oddities living well beyond our appointed time.”
But there is danger to a healthy, old life. The number of geriatricians in the United States has actually fallen by twenty-five percent between 1996 and 2010. Incomes of adult primary care physicians and geriatrics are among the lowest in medicine. I sincerely respect physicians and healthcare workers of all types. They are noble, but they must take care of themselves, their families, and others, too. And the elderly population is growing swiftly.
One sad fact is that, “Ultimately the average American spends a year or more of old age disabled and living in a nursing home (at more than five times the yearly cost of independent living). . . “ Planning for old age is something we don’t like to ponder. If it could only be like Felix and Bella. “At night they lay in bed in each other’s arms, awake and nestling for a while, before finally drifting off to sleep. Those moments, Felix said, remained among their most cherished. He felt they knew each other, and loved each other, more than at any time of their nearly seventy years together.” When Bella died, Felix “. . . had one great solace, however: that she hadn’t suffered, that she’d got to spend her last few weeks in peace at home in the warmth of their long love, instead of up on a nursing floor, a lost and disoriented patient.”
Another patient in a nursing home has a drastically different experience: “She felt incarcerated, like she was in prison for being old.”
In this review, generally, I am not going to describe the history of the care of the aged such as nursing homes, assisted living advances, and such. The details in the book itself do a wonderful job at that.
I really enjoyed Carstensen’s reflections and analysis of growing old as stated by Gawande. “Far from growing unhappier, people reported more positive emotions as they aged. They became less prone to anxiety, depression and anger. Living is a skill . . . The calm and wisdom of old age is achieved over time.”
Gawande reflected that how we spend our time may have a lot to do with how much time we expect to have left. If you’re young and healthy, you’ll surmise that you will live forever. “But as your time horizons contract—when you see the future ahead of you as finite and uncertain—your focus shifts to the here and now, to everyday pleasures and the people closest to you.” “It’s perspective, not age, that matters most.” People, in general, live in a manner that fits their own life’s timeframe.
Gawande describes the “. . . Three Plagues of nursing home existence: boredom, loneliness and helplessness.” I fully agree with his later statement that, “We all seek a cause beyond ourselves.” He writes, “The only way death is not meaningless is to see yourself as something greater; a family, a community, a society.”
In the United States, twenty-five percent of all Medicare spending is for the five percent of patients who are in their final year of life, and most of that money goes for care in their last couple of months that is of little apparent benefit. The question, therefore, is not how we can afford this system’s expense. It is how we can build a healthcare system that will actually help people achieve what’s most important to them at the end of their lives.
Gawande cited a study by sociologist Nicholas Christakis. In it he asked almost 500 doctors of terminally ill patients to estimate how long they thought their patient would live. Just seventeen percent underestimated it. The average estimate was 53 percent too high.
In a Coping with Cancer study, two-thirds of terminally ill patients stated they had no discussions with their doctors about end of life care. Most of those that did elected hospice care. “They suffered less, were physically more capable and were better able, for a longer period of time, to interact with others. In addition, six months after these patients died, their family members were markedly less likely to experience persistent major depression.”
One chapter ended with a touching scene when a father whispered into his daughter’s ear, “It’s okay to let go.” Gawande stated, later that morning, “she just stopped.”
Gawande put it beautifully in these words. “Our ultimate goal, after all, is not a good death but a good life ‘till the very end.”
This is a finely crafted and useful book, long overdue. I tried to decide at what age a person should be to read this book, partly because it pertains somewhat to disabled people as well as the elderly and all who care for therm. So, use your own judgment and perhaps read the book because it applies to you, or very well may soon.
Spiritually, I believe that for God, all things are possible. I believe in an eternal life in heaven, full of love. I do not see death vanishing anytime soon, but I do believe that God loves us with an enduring, steadfast love and that God has predetermined Heaven on Earth with humankind’s help and cooperation, someday, somehow.