Atul Gawande’s newest book, Being Mortal: Medicine and What Matters in the End, says a lot that matters. As a surgeon, writer, and son, he has seen older people and terminally ill patients suffer from health care designed to keep them safe and alive longer. Even if aggressive treatment prolongs life, it may spoil their remaining days. To prevent that tragedy, the book explores how to help seriously ill and older patients achieve what matters most to them as their time ebbs away.
In less gifted hands, this book on aging and dying could have been depressing but, for the most part, Gawande manages to celebrate living while facing human mortality head-on. He does so by introducing readers to some of the more than 200 people he interviewed about their own or a relative’s encounters with aging or serious illness. He adds cross-cultural notes by weaving in the experiences of his father, who immigrated to the U.S., and his grandfather, who stayed in India, where people valued him because of his age. He also recounts efforts to transform the care of older people and terminally ill patients.
Gawande, a surgeon at Brigham and Women’s Hospital and a professor at Harvard, wrote three other bestselling books on health care. He penned Being Mortal to understand why medicine often fails people when they most need help. To his credit, he spares neither himself nor his colleagues from criticism. Indeed, he writes, “Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.”
Old but not dead
Over the years, dying has changed from a quick strike to what Gawande calls “a long, slow fade.” He wrote, “As fewer of us are struck dead out of the blue, most of us will spend significant periods of our lives too reduced and debilitated to live independently.” The first part of the book stresses that patients and health-care providers should prepare for such times, despite our resistance to thinking about them.
To help us prepare, perhaps, Gawande describes how our bodies “fall apart” as we age, changes that he deems unstoppable. He paints such a grim picture of toothless old people whose shrinking brains rattle around in their skulls that some readers might be tempted to toss the book aside. I found this the weakest part of the book.
Doubtful about some of the changes Gawande attributes to aging, I checked a few of his sources but found little support for his claims. For instance, the study he cites to back his claim about the number of teeth lost by age 60 only looked at people age 65 and over. Besides, age-related need not mean age-caused: Data from five major U.S. surveys shows that, far from being inevitable, toothlessness has declined in all age groups studied and has nearly vanished from high-income households. I believe that Gawande overstates the inevitability of age-related changes and, in so doing, endangers the health of the very populations he wants to help. That’s because our beliefs about aging can become self-fulfilling prophecies that could harm our health and even shorten our lives.
Gawande regains his footing when he explores why many doctors dislike treating older patients. This highlights the need for more geriatricians, but I was disappointed to read in the book that the number of board-certified geriatricians dropped between 1996 and 2010. As baby boomers come of age, they will need more doctors with the desire and know-how to treat older people. Geriatric specialists help older people stave off disability longer, Gawande wrote.
Better functioning can keep people out of nursing homes, but Gawande notes that, in an effort to keep residents safe, nursing homes restrict nearly every aspect of their lives, from the clothing they wear to the food they eat. However, even people who need help value autonomy. Gawande wrote that his wife’s grandmother, who received nursing home care from a top-rated facility after she broke her hip, “felt incarcerated, like she was in prison for being old.”
Fortunately, the book mixes such woeful tales with stories of trailblazers’ efforts to remake elder care. Although I studied gerontology in graduate school, I had not heard the story of Keren Brown Wilson, Ph.D. As Gawande tells it, Wilson’s mother, in a nursing home after a stroke, asked Wilson to do something to help people like her. In response, Wilson and her husband built the first assisted living home for older people in the 1980s, hoping that its home-like environment and respect for residents’ autonomy would end nursing homes. That did not happen, and the story of Bill Thomas, a physician who became medical director of a nursing home, offers a delightful way to rethink them: He enlivened the place with 100 parakeets as well as dogs, cats, and more.
When less medicine is more
Seeing fresh approaches to elder care made Gawande think that stopping “the seemingly unstoppable momentum of medical treatment” might actually improve life for people who are terminally ill. In the book’s second part, he asks what medicine should do when it cannot save a patient’s life. He wanted answers not only to better serve his own patients, but also because an MRI had shown a tumor in his father’s spinal cord.
Sara Thomas Monopoli was 34 years old and 39 weeks pregnant when she learned she had advanced lung cancer. She bore a healthy girl, but then multiple rounds of chemotherapy with different drugs weakened Monopoli and could not keep the cancer in check. Still, she kept her fighting spirit, even when a PET scan found an unrelated cancer in her thyroid. When Gawande met with her to discuss surgery, he avoided suggesting that she stop fighting the cancer, even though that seemed the best course; he pegged his hopes on the slim chance that treatment might fix things.
It only made Monopoli sicker. Gawande sounds a bit wistful as he ponders whether he should have done more to help her and her family prepare for her last days. If he had, she might have benefited from palliative care or hospice. Seriously ill patients can receive palliative care any time, even while undergoing standard treatment. Hospice cares for patients who have 6 months or less to live, typically in their own homes. Both focus on patients’ comfort, physical and emotional.
With terminally ill patients, Gawande would mostly give information, but palliative care specialist Dr. Susan Block taught him that doctors should spend at least as much time listening to patients as talking to them. They should help patients face their fears and identify their priorities in case their health worsens. Gawande learned from palliative care specialists to not just present facts, but also the meaning behind them. Instead of “The scan showed spots,” he should say, “I’m worried about the spots I saw on the scan.”
When Gawande finally had the hard talk with his father, he learned that the senior Dr. Gawande would rather die than be totally paralyzed. That helped the family choose surgery, the option least likely to leave him quadriplegic. What his father valued most was interacting with other people, and he enjoyed receiving visitors in his home. Gawande wrote that his father “found that in the narrow space of possibility that his awful tumor had left for him there was still room to live.”
The book says only a little about assisted suicide or a “good death.” By focusing instead on how patients want to live until they take their last breath, Gawande presents a more upbeat framework that people may find easier to embrace. That may help patients, families, and health-care workers overcome emotional resistance to preparing for decline.
Gawande is not the first author to tackle many of the book’s themes, such as making the most of life as death lies waiting; I read about some of those issues in gerontology classes decades ago. Furthermore, readers of his New Yorker articles may recognize the material in two chapters. Still, I think most adults could benefit from reading Being Mortal because, as a whole, it shows we can find meaning and pleasure in late life, especially if we refuse to let our medical care get in the way. Indeed, this book is sparking conversations about the thorny topics of aging and dying, a huge step toward helping people realize what matters to them in the end.
Being Mortal: Medicine and What Matters in the End
By Atul Gawande
282 pp. Metropolitan Books/Henry Holt and Company. $26
Photo copyright victor69/123rf.com stock photo
Warren JJ, Watkins CA, Cowen HJ, et al. (2002 Feb). Tooth loss in the very old: 13-15-year incidence among elderly Iowans. Community Dentistry and Oral Epidemiology, 30(1): 29-37. http://dx.doi.org/10.1034/j.1600-0528.2002.300105.x
Slade GD, Akinkugbe AA, Sanders AE. (2014 Oct). Projections of U.S. edentulism prevalence following 5 decades of decline. Journal of Dental Research, 93(10), 959-965. http://dx.doi.org/10.1177/0022034514546165. Epub 2014 Aug 21.
Levy BR, Slade MD, Gill TM. (2006 Mar). Hearing decline predicted by elders’ stereotypes. Journal of Gerontology: Psychological Sciences, 61B(2), P82-P87. http://dx.doi.org/10.1093/geronb/61.2.P82
Levy BR, Hausdorff JM, Hencke R, et al. (2000 Jul). Reducing cardiovascular stress with positive self-stereotypes of aging. Journal of Gerontology: Psychological Sciences, 55B(4):P205-P213. http://dx.doi.org/10.1093/geronb/55.4.P205
Stewart TL, Chipperfield JG, Perry RP, et al. (2014 Feb 24). Attributing heart attack and stroke to “old age”: Implications for subsequent health outcomes among older adults. Journal of Health Psychology. Epub ahead of print. http://dx.doi.org/10.1177/1359105314521477
Stewart TL, Chipperfield JG, Perry RP, et al. (2012 Aug). Attributing illness to ‘old age:’ Consequences of a self-directed stereotype for health and mortality. Psychology and Health, 27(8): 881-897. http://dx.doi.org/10.1080/08870446.2011.630735. Epub 2011 Dec 12.
Levy BR, Slade MD, Kunkel SR, et al. (2002 Aug). Longevity increased by positive self-perceptions of aging. Journal of Personality and Social Psychology, 83(2):261-270. http://dx.doi.org/10.1037/0022-35220.127.116.111
Sedensky M. (2011 Nov 6). Shortage in geriatricians worsens as boomers age. The Denver Post. http://www.denverpost.com/ci_19273702