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

Summary: Our current system of caring for the elderly and sick could be better.

Mortality is something that no one really likes to consider. However, Atul Gawande, a general surgeon and author of a number of books thinks we need to spend a lot more time thinking about it. (Notice the subtle, but brilliant blade of grass on the cover.)

Being Mortal is about our end of life health and care system. Because Gawande’s father is an immigrant from India, he opens the book talking about the difference between the older systems of family care (and what is still practiced in many parts of the world including India) and our Western independence focused system of care. While Gawande thinks there are many things to be said for being around family and multi-generational living, the reality is not always good. Those that do not have children have no system, the children’ may need to give up opportunities if it requires moving away, and regardless, the elderly themselves would often prefer to be on their own.

Prior to Social Security and Medicare, most elderly were in poverty and approximately 2/3 of the residents of poor houses (think Dickens) were elderly. Those poor houses were still operating in the US until being slowly shut down in the mid-20th century.

At the same time medicine improved, hospitals spread, and care of the elderly moved from home health (or institutional poor houses) to hospitals. This created a problem for the relatively new hospital system as the long term sick were monopolizing a larger percentage of the (expensive) beds. Starting in the mid-1950s hospitals opened up attached nursing homes to care for long term sick and this was included in the Medicare and Medicaid programs of the 1960s, greatly expanding the number of beds and their use.

However, nursing homes were developed to ease the burden of hospitals and to make money, not primarily give dignity to the dying. So it was not long before the first Assisted Living centers started. The initial idea (which Gawande shows has now largely been abandoned because of profit maximization) was to help the elderly live as independently as possible, with a kitchen in every room and a door that would lock. Tweaking of nursing home care has continued as well, first becoming government regulated and safer and now trying to become more personalized, giving still adult choices about when to get up and eat and what to eat and to include basic amenities such as pets and live plants.

Gawande does not stop at housing, he also tackles doctors and end of life medical decisions. One of the most striking things in his research is that when asked what results significant medical intervention, like chemotherapy and radiation, etc would have, most patients expected a 10 to 15 year extension of their life. While their doctors tended to expect a 1 to 3 year extension from the same interventions.

Throughout the book, Gawande helpfully recounts and contrasts stories, many of them personal, like his 110 year old Indian grandfather and his wife’s grandmother. It was his own father’s story that was most important to the book. Gawande, his father, and his mother were all doctors. At one point he says that between the three of them there was more than 100 years of medical experience, but still they had a hard time understanding the different treatment options available to them for his father’s cancer.

The next to the last chapter, about having tough conversations around what your desires and expectations are with end of life care, is well worth the price of the book. While I think that the whole book should be required reading for pastoral care classes, this chapter is absolutely essential. This is more than talking about Do Not Resuscitate orders and living wills, Gawande is advocating real discussion about what it would take to feel like your life is still worth living. For instance, one man told his daughter when confronted with a surgery that might leave him paraplegic said as long as he could watch football and eat ice cream he would considered that acceptable, when doctors had complications during surgery and asked for her instructions, she was able to feel confident that she was upholding her father’s wishes.

This is not a Christian book (from what I can tell Gawande is a non-practicing Buddhist), but there a number of tough subjects that are brought up and delicately handled. The medical system is not the hero of much of this story, although there are many individual heroes that work within the system and have their stories told here. Most of the time we tend to ignore death until it is too late, I would encourage you to pick this book up now start thinking about it before you need it.

Being Mortal: Medicine and What Matters in the End by Atul Gawande Purchase Links: Hardcover, Kindle Edition, Audiobook 

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