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March 15, 2015

Being Mortal



Being Mortal: Medicine and What Matters in the End by Atul Gawande
Nonfiction – Medicine
2014 Metropolitan Books
Finished on February 24, 2015
Rating: 4.5/5 (Terrific!)



Being Mortal is an AARP, Amazon, Apple iBooks, Astoria Bookshop, Book Riot, Business Standard, Chicago Tribune, The Daily Beast, The Economist, Financial Times, The Globe and Mail, The Guardian, Houston Chronicle, Huffington Post, LA Times, Maclean’s Magazine, Mother Jones, New Hampshire Public Radio, The New Statesman, The New York Times, NPR, NPR’s Science Friday, Oprah, Politics & Prose, Shelf Awareness, Wall Street Journal, Washington Post, and Wired Magazine Bestseller. [It was also a Barnes & Noble Best Book of 2014.]

Publisher’s Blurb:

Medicine has triumphed in modern times, transforming the dangers of childbirth, injury, and disease from harrowing to manageable. But when it comes to the inescapable realities of aging and death, what medicine can do often runs counter to what it should.

Through eye-opening research and gripping stories of his own patients and family, Gawande reveals the suffering this dynamic has produced. Nursing homes, devoted above all to safety, battle with residents over the food they are allowed to eat and the choices they are allowed to make. Doctors, uncomfortable discussing patients’ anxieties about death, fall back on false hopes and treatments that are actually shortening lives instead of improving them. And families go along with all of it.

In his bestselling books, Atul Gawande, a practicing surgeon, has fearlessly revealed the struggles of his profession. Now he examines its ultimate limitations and failures – in his own practices as well as others’ – as life draws to a close. And he discovers how we can do better. He follows a hospice nurse on her rounds, a geriatrician in his clinic, and reformers turning nursing homes upside down. He finds people who show us how to have the hard conversations and how to ensure we never sacrifice what people really care about.
Riveting, honest, and humane, Being Mortal shows that the ultimate goal is not a good death but a good life – all the way to the very end.

“You’re as young as you feel!”

Right??

Or, maybe it’s more like, “You’re not getting any younger!”

Whatever.

I’ve always felt much younger than the date on my driver’s license, but last week, while writing about a book in which a 53-year-old woman is referred to as middle-aged, I stopped dead in my tracks. Really? Middle-aged? But, 53 is middle-aged. So why is that so difficult for me to accept? Isn’t 50 the new 30? (Someone really should mention this to my back and knees.)

I had my first experience of extreme back pain a couple of years ago (who knew lifting one large duffel bag into the back of an SUV could cause such pain!) and now I need to be extra careful when lifting heavy boxes of books at work. Gone are the days of running 3-5 miles, thanks to over 30 years of pounding the pavement, so walking and biking have replaced that passion for a runner’s high. I now own a half dozen pairs of readers, as well as my first pair of bifocals (which I never got used to and have stashed in my purse for emergencies), and while I hate to admit it, I think my hearing is not what it used to be. If there’s too much background noise and I have my back to the room (washing dishes, for instance), I really can’t hear what my husband is saying if he’s in an adjacent room. And, those extra pounds that used to be so easy to drop with just a few simple modifications to my diet, combined with an increase in my exercise routine? Ha! I’m falling apart. Thankfully, more slowly than my husband, but then, he has a decade on me.

So what does all this whining have to do with Atul Gawande’s latest book? Well, it’s pretty obvious that one day we’re all going to die, but this book really got me thinking about how we are treating our elders and how I hope to enjoy my final years of life. Never too early to start worrying, right?

I started listening to Being Mortal on audio, but found my mind wandering, so I decided to switch over to the print edition. This turned out to be a good thing, since I wound up with over a dozen passages marked for future reference. This book is filled with many anecdotes and much information about aging, nursing homes, hospice, etc., and it’s one you’ll want to share with your spouse, hopefully inspiring some heartfelt discussions about planning for “the golden years.” It’s also a great book to share and discuss with your parents, although that might prove to be a bit more uncomfortable than with your spouse. We are a society that loathes to talk about grief, let alone dying. But if we don’t learn our loved-ones' wishes while they can still share them with us, we might not know what their desires are when it’s too late to discuss.

On scientific advances in medicine:

Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it.

This reality has been largely hidden, as the final phases of life become less familiar to people. As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did. Those who somehow did die at home likely died too suddenly to make it to the hospital—say, from a massive heart attack, stroke, or violent injury—or were too isolated to get somewhere that could provide help. Across not just the United States but also the entire industrialized world, the experience of advanced aging and death has shifted to hospitals and nursing homes.

and

There’s no escaping the tragedy of life, which is that we are all aging from the day we are born. One may even come to understand and accept this fact. My dead and dying patients don’t haunt my dreams anymore. But that’s not the same as saying one knows how to cope with what cannot be mended. I am in a profession that has succeeded because of its ability to fix. If your problem is fixable, we know just what to do. But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering.

This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing.

On nursing homes:

It is a near-universal reality. Nursing home priorities are matters like avoiding bedsores and maintaining residents’ weight—important medical goals, to be sure, but they are means, not ends. The woman had left an airy apartment she furnished herself for a small beige hospital-like room with a stranger for a roommate. Her belongings were stripped down to what she could fit into the one cupboard and shelf they gave her. Basic matters, like when she went to bed, woke up, dressed, and ate, were subject to the rigid schedule of institutional life. She couldn’t have her own furniture or a cocktail before dinner, because it wasn’t safe.

There was so much more she felt she could do in her life. “I want to be helpful, play a role,” she said. She used to make her own jewelry, volunteer at the library. Now, her main activities were bingo, DVD movies, and other forms of passive group entertainment. The things she missed most, she told me, were her friendships, privacy, and a purpose to her days. Nursing homes have come a long way from the firetrap warehouses of neglect they used to be. But it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.

On simple pleasures:

As our time winds down, we all seek comfort in simple pleasures—companionship, everyday routines, the taste of good food, the warmth of sunlight on our faces. We become less interested in the rewards of achieving and accumulating, and more interested in the rewards of simply being. Yet while we may feel less ambitious, we also become concerned for our legacy. And we have a deep need to identify purposes outside ourselves that make living feel meaningful and worthwhile.

On the dying role:

Technological society has forgotten what scholars call the “dying role” and its importance to people as life approaches its end. People want to share memories, pass on wisdoms and keepsakes, settle relationships, establish their legacies, make peace with God, and ensure that those who are left behind will be okay. They want to end their stories on their own terms. This role is, observers argue, among life’s most important, for both the dying and those left behind. And if it is, the way we deny people this role, out of obtuseness and neglect, is cause for everlasting shame. Over and over, we in medicine inflict deep gouges at the end of people’s lives and then stand oblivious to the harm done.


As I finished the final chapter of Atul Gawande’s thought-provoking work, I felt a sense of deep sadness, perhaps because his father’s final days reminded me of the last days I spent with my stepfather, who died on December 15, 2013. Both men died of cancer, in their homes, surrounded by their families, under the care of hospice. It may sound strange to those who have never experienced the passing of a loved one in hospice, but as my stepdad took his final breath, with only candles burning to illuminate the bedroom, his wife and adult children holding his hands and gently touching his arms and back, I couldn’t help but think that it was one of the most beautiful and peaceful moments I’d ever experienced. Of course it was extremely sad, but I can’t think of a better place to say our goodbyes. Certainly not a noisy, sterile hospital room, that’s for certain.

Final Thoughts:

If you only read one book in 2015, Being Mortal is my #1 recommendation for a nonfiction title. I can’t recommend it highly enough. Couples will find plenty of information to use in discussions about their futures as senior citizens, as will adult children with their aging parents. And, of course, members of book groups will have plenty to share about their individual hopes (and fears) to live out their final years not simply with good health and comfort, but also with pleasure and dignity.

Middle-aged? I guess it’s really just a state of mind. While I’m not quite ready to order off the senior menu at Las Margaritas, I do have lots to look forward to in the coming years.

Joie de vivre!

Atul Gawande is the author of The Checklist Manifesto, Better, and Complications. He is also a MacArthur Fellow, a general surgeon at Brigham and Women's Hospital, a staff writer at The New Yorker, and an assistant professor at Harvard Medical School and the Harvard School of Public Health. He lives with his wife and three children in Newton, Massachusetts.

Go here to listen to Atul Gawande’s interview with Diane Rehm on NPR.

8 comments:

  1. Carl and I are middle aged and have both lost a parent so this book sounds perfect for us. I do want to point out that not all hospices are equal - they only checked on my father once during the last week of his life. They didn't offer to stay with us and gave us instructions on what to do when he "expired."

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    1. Kathy, I'm so sorry that your father had a poor experience with hospice. :( I suspect it's like any health care provider or institution. There's bound to be some that are far less than desirable. Unfortunately, it's not the sort of thing you research too easily, I suppose, since it's usually needed during a period of crisis, when all involved are feeling very vulnerable.

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  2. We are firmly in the middle-aged camp, too, and I plan to read this book before too much longer. I will take your advice and read though... moving it from audio to print wish list. Great review, Les!

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    1. Yes, JoAnn. Definitely read it. Have some post-it flags and a highlighter handy, too. Thanks for your kind words.

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  3. I totally agree with your assessment of this book. Very, very highly recommended. There are many difficult topics discussed, but having gone through the process of making these decisions for both my parents and helping my sister and her family with her decisions before her death, thinking and talking about life and life's end is helpful. It's hard enough even when you've done that. My experience with hospice for all 3 of my family members was very positive, but I'm sure that, as Kathy says above, not all are the same. We were lucky to get to use the same hospice for each of our loved ones.

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    1. Kay, I just re-read your excellent review (which posted the day after I finished this book). It's an outstanding book, isn't it? Do you think your daughter will read it? If my daughter was a reader, I'd give her a copy. Since she's not, I guess I'll just have to have some heart-to-heart chats with her in the coming years about my wishes for the end of my life. My hubby's already been informed. :)

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  4. We had my father at a wonderful assisted living home for a while. His room was almost as large as an apartment with a kitchen area, fridge, sink (no stove), but eventually, we had to move him to a nursing home because he needed more medical care and was past appreciating the benefits of his "hotel." It does make you much more aware of varying circumstances--he went from cheerful (he did think he was staying in a hotel) and social and wonderful meals to...concern about bed sores, drab, and depressing.

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    1. Jenclair, my grandmother was in a very nice apartment in a retirement community, too. She had her own apartment with a bedroom, bathroom, living/dining area, as well as a small kitchenette. She could have friends over for drinks and nibbles before dinner, which was nice since she was very social. She ate most of her meals in the community dining room and did exercises in the community pool. It really was like living in an apartment complex! She never did have to go into the nursing care unit of the facility, since she passed away before she became an invalid. I'm sure that last transition into "a room" is very depressing. I think, in many ways, my grandmother was lucky to miss that part of her final stage in life.

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