Gawande, Atul. 2014. Being mortal: Medicine and what matters in the end. NY: Henry Holt and Company.
Atul Gawande is a surgeon at Brigham and Women’s Hospital in Boston, a professor at Harvard Medical School and the Harvard School of Public Health, as well as an acclaimed writer.
Gawande takes us where few medical doctors are willing to go: the end or near end of our lives when difficult decisions must be made. He does so by telling us stories about patients that he has treated or consulted with, often admitting that he could have done things better.
Gawande’s parents, both physicians, immigrated from India and the story of the sickness and death of his father reminds us of the decisions that all of us must make, hopefully, but unfortunately not often, with the help of our family doctor.
Gawande tells us that “You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help” (9), which should alarm us or at least make those of us who are ‘elderly’ sit up and take notice. We want to be independent, as all real red-blooded Americans seem to wish, not bothering our children—or anyone, if it can be avoided. It can’t of course, but that is our grand independent illusion and one that Being Mortal can help us overcome.
Of course, looking at old age and being old are different in many parts of the world, including India or, for that matter, Papua New Guinea. The elderly are not put in homes, they are looked after by their families.
We are reminded that life goes along well until “things fall apart” and in our American society they fall apart, are somewhat resurrected, only to fall apart again, even if there are several stages in the process. But there does not seem to be any particular, reproducible pathways to aging, “We just fall apart” (35). And, when we do, there are various scenarios, from the “I just want to die at home” to the “Let’s do everything possible to keep him/her alive”. Retirement ‘homes’ and nursing facilities are the fastest growing part of the health industry and the elderly invest or commit the better part of their life’s savings to these institutions or to the medical professionals who treat them. Gawande, quoting others, reminds us that “Old age is a continuous series of losses” and that “Old age is not a battle. Old age is a massacre” (55). He wonders why we have wound up “where the only choices for the very old seem to be either going down with the volcano or yielding all control over our lives” (68).
Old people need assistance and often their families cannot provide it. Once debilitated, the elderly need a “combination of the technological and the custodial” (85), helping with medications and specialists. In the absence of family care, the elderly have no choice but are often left with “a controlled and supervised institutional existence” (109).
Is there a better way? Gawande believes there is and he gives us some examples that are now taking place. Some nursing homes now allow animals to be with patients, more interaction with the medical professionals, and so on, but a key to better health maintenance seems to be the environment, as well as a certain level of autonomy.
One of the most difficult decisions at the end of life is “letting go”, both by the patient and the family. In addition, the costs are high. A 2011 study of breast cancer patients showed that for the first year the patient spent an estimated $28,000 because of “diagnostic testing, surgery, and where necessary, radiation and chemotherapy” (153), then fell to about $2,000 a year but, if fatal, an average of $94,000 during the final year of life. As Giwande notes, the question is how to “build a health care system that will actually help people achieve what’s most important to them at the end of their lives” (155). Doctors typically overestimate how long they think a patient will live and “the better the doctors know the patients, the more likely they were to err” (167). We imagine ourselves to have more time than we do and wish to fight, “to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh”, even if we shorten or worsen our lives (173).
A form that is used in some places to help patients make informed decisions asks (179):
- Do you want to be resuscitated if your heart stops?
- Do you want aggressive treatments such as intubation and mechanical ventilation?
- Do you want antibiotics?
- Do you want tube or intravenous feeding if you can’t eat on your own?
Such questions are included in advanced directives that patients sign and date. As Gawande says, “Death is the enemy. But the enemy has superior forces…And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation” (187).
Decisions like these involve some “hard conversations” (the title of chapter 7). Doctors may have a paternalistic relationship or an informative (retail) relationship with their patient. But the patient often wants an interpretive relationship, where the doctor tries to find out what is really the most important to the patient. But the choices are relentless, although the choices are in one direction because the only fear than clinicians seem to have is to do too little, not recognizing that “doing too much could be no less devastating to a person’s life” (220).
Gawande speaks of courage, following a conversation of Socrates and his two generals, defined as “wise endurance” (231). Patients need to express their biggest fears, things that are most important to them, and what trade-offs they are willing to make. One thing is certain: no one wants pain and “Just a few minutes without pain at the end of their medical procedure dramatically reduced patents’’ overall pain ratings even after they’d experience more than half an hour of high level of pain” (237).
Our life is a story and we want the story to have a good ending and one that we can help determine and recognize. And we will need assistance—“Assisted living is far harder than assisted death, but its possibilities are far greater, as well” (245).
Gawande concludes that “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” (259). The task of the doctor is therefore to enable well-being, which means examining our situation and its potential outcome, expressing our fears and hopes, the trade-offs we are willing to make.
Gawande does not express the hope that a Christian has, nor should we expect him too. His father, a Hindu, died peacefully and within the compassion of his family. Christians should be able to do the same, but with the hope that, like the caterpillar than turns into a beautiful butterfly, our decrepit bodies will be shed and new vital ones will replace it.
“Bur we must wait our turn. Christ was the first to be raised to life, and his people will be raised to life when he returns” (I Corinthians 15:23).