Being Mortal: Medicine & What Matters in the End

Dr Atul Gawande poses an exploration of perhaps the most relevant question we should be asking as we march inevitably towards the end.

Dr Atul Gawande

Dr Atul Gawande

Humanity has spent so long trying to achieve longer and longer lives, and along the way, seemed to have forgotten how to die, least of all, how to grow old.

Atul Gawande, a Boston based surgeon and staff writer for the New Yorker, took pen to paper to address what he, as a practicing man of medicine, noticed was a severe lack in the modern worldview of healthcare; the result is his critically acclaimed book, 'Being Mortal: Medicine & What Matters in the End.'

Divided into two parts, this impassioned and slightly poetic piece of non-fiction feels more like an evolutionary journey, a revelation through a multitude of experiences.

In the first part, Gwande points out an obvious fact that so much of us have not given due attention to; the culture of trying to achieve longevity has created an almost militaristic determination to try and cure nearly every ailment, including those accompanying old age. 

He assesses the current state of healthcare, how medical breakthroughs have made miracles commonplace, how diseases that crippled entire societies have now been brought to heel, and also the rampant, ignorant, march of progress. To illuminate this point, he describes his experience as an intern to the neurosurgery service, where he observed a terminally ill patient and their decisions. It seemed like the finality of his condition was never given the proper attention, and that the doctors and family involved in the decision making processes only dealt in hope. Hope, that was derived from the very minuscule, miraculous chances of recovery, but hope nonetheless. It was this hope that had sealed the fate of the patient.

In more cases than this, he describes how this sort of arrogance in the face of old age forced patients to take upon treatments that had lesser and lesser chances of success, leading to a fate far worse than the demise from the illness. Major breakthroughs in treatment did not equal a sure-fire recovery, and more often than not, the treatment itself is what causes all the more pain to the patients, even causing them to pass away without being able to say their proper goodbyes.

Gawande touches upon the historic by reminding the reader that death was usually quite sudden in ages past. An illness like tuberculosis or even heart disease, previously untreatable, made the concept of death a short-lived experience, for the victim as well as those around them. Yet, with the advent of longevity through medical science, so many people are living past 80, which used to be the exception rather than the rule, and death by old age has not been given due attention. How does one approach old age? What are the responsibilities of medicine in this period of a person’s life?

In the last fifty years, nursing homes, previously established to house terminally ill and those constantly in danger, were being switched over for the care of the old. This was a necessary change, as the old who did not have entire autonomy over their lives due to loss of their abilities over the years, were previously being put in almshouses, where they were forced to live in bleak conditions, dependant on charity. Yet, nursing homes, Gawande rightfully points out, approached the issue purely from a medical perspective, and the down side of this approach was only felt by those housed in such places. 

Since they had physical immobility issues, high risks in both movement & intake of food, and lack of cranial abilities, nursing homes were run strictly to a schedule, and nearly every daily activity of those housed there were hijacked by the staff according to strict SOPs. Gawande describes how being assigned to a nursing home was equal to a life sentence in penitentiary; an institution that dictates every step of someone’s daily life, albeit with the intent of reducing risk, yet entirely taking away what it means to be alive.

The second part of the book asks the more important, underlying, question; “What is more important to you?”

Those approaching old age and those with terminal illnesses needed to have that question asked to them, including the fact that death is inevitable, regardless of the slim chances medical services might promise. They were to be asked how much they were willing to go through for a chance at a longer life, and also what exactly it is that they would like to be able to keep on doing. One patient in the book pointed out he would prefer to retain the ability to sit in his armchair and watch sports while being able to hold and have a drink by himself. This alone was paramount to the final decision; most treatments carried the risk of paralysis, the risk of making matters worse, or even creating problems where there were none. They were also asked if they were agreeable to being put on intensive care, or if they wanted to be resuscitated if their body could not keep going. Then, they were given the chance, and the reasons, to decline treatment.

Gawande opens the eyes of his readers to the chance that doing nothing might be better than going all out and trying risky procedures. He proves this point by taking the second part of the book to focus on hospice and palliative care, care that focuses on reducing pain and making life more liveable. By affording those who have little time the chance to live out the way they would want to, to the best of their abilities with proper support and encouragement, was what allowed Gawande’s father, with terminal spinal cancer, to approach his inevitable end with as much grace and dignity as he could have hoped for. It was extremely heartwarming to read about how Gawande senior managed to outlive expectations and walk with pride to the podium during the graduation ceremony of a college he had built himself.

The book wraps up with the author taking part in the funeral rites as was required of him as a son, and how even towards the end, he had been less of a surgeon and more of a son, mired in emotions and still trying to learn from his experiences with his own patients. He comes to the culmination of a point he had noted in the onset, and does this gracefully. The message resounding through Being Mortal is that our lives have narrative – we all want to be the authors of our own stories, and in stories, endings matter. Doctors and other clinicians have to get better at helping people with their endings, or else more and more of us would find our exit sequence played out with multiple tubes in and out of us, a loss of cognitive ability to see our loved ones, and a loss of voice to say goodbye. 

For a non-fiction piece, the book is a must read for everyone, especially those going through the immensely difficult times of letting someone go. Well written, well rounded, and poetic without being superficial, Atun Gawande’s best work is a must have for reading nooks around the world.

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