Review: Being Mortal: Medicine and What Matters in the End, by Atul Gawande

Author Atul Gawande is an American surgeon, writer and public health researcher; he practices general and endocrine surgery at Brigham and Women’s Hospital in Boston, Massachusetts. His personal experience regarding the subject of aging and mortality includes a grandfather who lived to be 110, his father who experienced cancer, and his mother-in-law’s aging and dying process. Professionally, he was often called upon to perform last chance surgeries on patients in a medical system that doesn’t like to admit defeat.

Many of these surgical procedures didn’t provide clear benefits, but in today’s medical world, a lack of action is equated with giving up. Gawande learned the hard way that though medicine could offer endless treatments to prolong life, in most cases, additional treatment did not serve the patient’s deeper wishes, and often made matters worse. These “heroic measures” also greatly interfered with a peaceful and connected exit; it’s hard to talk when you’re intubated.

Gawande unflinchingly explores the nursing home and assisted living options today. Once again, it’s clear our country and health care system have “issues”. Being Mortal addresses these areas as it elegantly and intelligently explores (the book’s subtitle) “medicine and what matters in the end”.

You’ll hear an amazingly informative history of how our current nursing homes came to be. Have you ever heard the term poorhouses? My great aunts would use this term in a joking matter, such as, “Oh no, then you’ll wind up in the poorhouse”. This was clearly something to avoid. In the early 1900s, before social security and pensions came about, poorhouses housed all types who didn’t have money or family support – “elderly paupers, out-of-luck immigrants, young drunks, the mentally ill”. Conditions were awful, and one report from 1912 named conditions as “unfit to decently house animals”.

It was 1935 when social security was established, providing some cushion for the elderly, widowed, disabled etc., enabling alternative options. There was still a gap though, and nursing homes, and eventually assisted living facilities, increased in numbers.

Then, after WWII, medicine changed dramatically. Drugs to treat infections, to control blood pressure, to treat hormonal imbalances, were created. Huge strides were made such as heart surgery, artificial respirators, kidney transplants. The role of doctors and hospitals shifted from more of a warehouse, to “a place of hope and cure”. Before this, doctors usually made house calls and treated you in your bed; imagine that. Alongside this shift in medical practice, in 1946, the Hill-Burton act provided large federal funding for hospital construction. Within 20 years (1966), 9000 new hospitals had been built. Medicine became something that could sometimes provide magical solutions, and most people now had a hospital nearby.

I hadn’t realized much of the history to this changing face of medicine, aging and death. For example, two hundred years ago, the average age of death? 28 years old. Death happened fast and at home. Today we live longer, it’s true. Though medicine offers endless options to stay alive, in the end we may not need or desire so many options, and they have a cost. Most do no really want to die attached to machines or live for years warehoused in nursing homes.

But facing the truth about death and how we do and don’t want to die and be cared for – well that is a very difficult, many-layered conversation to have. Doctors are not usually trained to the depth these areas demand. Specialists who handle this area, gerontologists, have drastically decreased in number. It’s a less lucrative and more challenging field, to treat multiple uncurable illnesses that eldercare usually entails. Socialized medicine would yet again save our asses here, one would surmise.

As with many situations in life today, it’s quite a mess out there in our overly profit-driven, out of date, and disconnected-to-values medical bureaucracy. In this case, the technology has outpaced the human heart’s wisdom and common sense. This is a common side of effect of superfast evolution. Let’s hope system corrections and revisions can still be made that honor these endings and the changes to the circle of loved ones.

Gawande made a huge contribution with Being Mortal. He lets us see alternatives to the current model. Several terminal patients including his father and mother-in-law, are followed in detail in very instructive ways. You see successful and failed conversations, decision-making challenges, violent and peaceful deaths. You watch as hospice and palliative care options give families weeks of deep and timeless connection at home, before a peaceful death. You note how to ask medical professionals the nitty gritty questions you need answered. You learn the four questions to ask yourself and your loved ones, to determine what is most important.  Since we often learn best by others’ stories, these cases are awesome instruction. Gawande also covers several nursing home/assisted living alternatives that give us hope for the creation of a more kind and inspired end zone game.

Having spent nearly twenty years as a counselor for cancer patients and families, questions about health, navigating the medical system, and dying well with family and friends – this has a special place in my heart. Both of my parents have passed, so I am not currently a caregiver for an elder, as are many people my age. For anyone touched by questions of how to improve clarity, preserve quality of life and attend to what is most meaningful, as we knock on “heaven’s door” – whether personally or professionally – this book is a godsend. Read it and weep, yes; but read it and receive its gift of knowledge and wisdom. Gawande is a humble and inspired guide on how to best support your loved ones and friends with a peaceful and honorable transition into the beyond.

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