Being Mortal: Medicine and What Matters in the End

View in Browser   Key insights from Being Mortal: Medicine and What Matters in the End By Atul Gawande

What you’ll learn Four glowingly bare hospital walls watch as patients slip out of life. Ventilators and breathing tubes, intrusive IVs, and beeping equipment make up the components of a modern-day death. Despite the fact that medicine is more advanced than ever, it’s made the process of dying more brutal as patients lose their dignity in the hopeless pursuit of more life. Prior to 1945, a majority of deaths took place in the familiarity of the home, but by the 1980s that number plummeted to 17%. Culture views medicine as an incorruptible tool, a safeguard against mortality, but sadly, that’s not the case. Bestselling author and surgeon Atul Gawande takes readers through a poetic observation of the modern experience of dying, unraveling its evolution and diagnosing how we might better protect the humanity of those we are losing.   Read on for key insights from Being Mortal: Medicine and What Matters in the End.

1. The process of aging withered from a collective art to a solitary act. Riding briskly along the perimeter of his farm in Uti, Sitaram Gawande strode into old age with few difficulties. For safety reasons, his horse was much smaller now and one of his sons accompanied him on his survey, but he was still riding and that’s all that mattered. Years of his life weren’t dwindling off to a form of living that was less than he knew in the past. The author notes that his grandfather’s experience of aging was indicative of the regard with which Indian families upheld their elders. Coming from a background of generational reverence for the silver-haired wisdom of their older counterparts, the author was shocked to discover the way his American girlfriend’s grandmother lived. Alice Hobson lived alone, but she wasn’t lonely or feeble—far from it, actually. She went to the gym, spent time with friends, and made deliveries for Meals on Wheels. What happened to the multi-generational support system as stable as the beams of a beloved family home? Prior to the 18th century in the United States and Europe, most elderly people actually exaggerated their age. The treatment of elders bordered on royalty; they were the all-knowing sages of society, consulted on all issues and discussions. It was simply common knowledge that their lives would stretch into old age within the comfort of their homes, provided for by at least one member of the family. The brilliant poet Emily Dickinson is one such example of this, spending all her days tending to her aging parents and writing away in her childhood bedroom. Until the 18th century, aging was a crown that gained more gems with every year passed, but that’s not true anymore.  Modern medicine allows people to live longer, so the population of elderly people is growing greater than before. In fact, China boasts a record-shattering 100 million elderly people as a part of its community. With prolonged life and ability, the elderly and their previously accommodating families sought more independence and autonomy. Social scientists call this trend “intimacy at a distance,” noting that whenever it was within their means, elderly people preferred to age while maintaining self-reliant lives. In Europe, a slight 10% of elderly people live with their children now. While increased independence allows the elderly to flourish on their own, fostering a new kind of free life, it is also prone to dissolution. There will come a time when the horse rides grow impossible and gym sessions unthinkable. Society slips in to catch the eldery when they fall, but the hands of hospitals aren’t always strong enough to hold them.

2. Nursing homes evolved from a shortage of hospital space—now, they inhibit happiness. The average Roman lived a short (and pretty violent) 28 years, a fact that appears tragic and unthinkable to us now. Our society is a product of “rectangularization,” which means that our population of elderly is just as plentiful as our population of children. Previously, our population formed a pyramid with the elderly at the top as the most sparse population, but breakthroughs in medicine and sanitation have extended life beyond our healthiest years. Still, no one is immune to aging and dying. Former geriatric doctor Felix Silverstone looks at aging as a collective bodily process; there’s no particular insufficiency or setback that spurs one’s drawing towards death. Rather, aging is a slow and delicately collapsing tent that caves in on itself as one corner folds here and a bit of tarp rips there. When people age and begin to lose complete autonomy, institutions step in to help. While these seemingly well-intentioned institutions prolong life for the elderly in the safest ways possible, they do so at the expense of actual satisfaction and happiness. Nurses and healthcare workers may remind men and women to take their pills and eat proper meals, but their words crystallize into callous commands that strip the elderly of personal freedom. In 1912, prior to the development of facilities that maintain elderly life, the aging who could no longer work or take care of themselves were driven to the devastating conditions of poorhouses, or shelters established by the government to house the sick and impoverished. Despite the enactment of the Social Security Act in 1935, the elderly population remained high within those poorhouses, due to illness and their inability to care for themselves. With the development of government welfare programs, poorhouses began to topple through the 1950s, causing elderly residents to look elsewhere for help. Simultaneously, due to medical advancements throughout WWII, like the discovery of penicillin and other antibiotics, the hospital’s purpose began to shift. Now, the cultural imagination perceives the sleek interior of the hospital as a haven with a cure. The displaced eldery were soon sent there. Placing the elderly into hospitals was simply society’s not-so-easy way out of dealing with the real problem: inevitable aging. Soon, hospital beds filled with people succumbing to the incurable process of aging. In 1954, after entreating the government to respond to the conditions of their over-wrought facilities, hospitals developed special units for elderly people that freed up hospital beds for patients with more temporary afflictions. Now, the average American spends at least a year in one of these nursing homes.  It’s difficult to envision an alternative to the nursing home, but it’s necessary if society desires to create a more satisfying end to human life. To do this, each of us must reach beyond the stale air and constrained environment of the nursing home to ask the aging a crucial question: What do they really want?

3. Aging isn’t the end; in fact, it’s only the beginning of fulfillment. To nurture fulfillment throughout the aging process, physicians and loved ones alike must ask people what they really hope to cultivate in their last stage of life. The answer is integral to discern whether the choices to seek medical treatment or move from one’s home into a more controlled environment are consistent with personal desires. If a nursing home destroys a person’s happiness, making it nearly impossible for them to feel self-sufficient, is it truly worth it?  This is a question Keren Brown Wilson pondered while watching her mother’s years slip off in the dismal space of a nursing home. Her mother had a question for her, too: What can you do to help people like me? This made Wilson wonder, what if there was another way to assist the elderly without taking away their autonomy? What if the nursing home wasn’t the final trumpet blow to our aging lives? Wilson sought to construct a facility which enabled the elderly to live both safely and freely within a space that felt like home but was still sparsely monitored. In 1983, the “living center with assistance,” or what we know as assisted living, sprung into existence in Park Place, Portland. Free from constant monitoring and pestering to take medications or constantly follow the orders of another person, elderly people were able to maintain their own lives as independently as possible.  Similarly, this development embodies a psychological principle Stanford psychologist Laura Carstensen discovered while laying on a hospital bed after a nearly fatal car accident. Her work asserts that as we age, our motivations change. Instead of looking to widen our circle of friends, experiences, and knowledge, we’d rather move deeper into the present. She found that elderly people were more likely to feel fulfilled and free from anxiety and depression through their appreciation of the present. They focus on relationships with loved ones and look to their present circumstances for satisfaction instead. Carstensen calls this trend “socioemotional selectivity theory,” and it results from one’s perception of one’s remaining time on earth. Death is a more immediate presence for an elderly person or an ill patient than for a teenager, and so dying people shift their motivations accordingly. Instead of looking for joy later, they look now—the only moment with the potential to provide meaning in a deteriorating reality.

4. Meaning is medicine for the elderly and the ill. A life without meaning is unlivable. Still, we confine people to it everyday as we force them to stay put in their safely-monitored nursing home apartments or tucked into the cold sheets of a hospital bed. Geriatric doctor Bill Thomas saw the error in prizing security over happiness during his time at the Chase Memorial Nursing Home. While there, he endeavored to address three problems inherent in nursing homes: boredom, loneliness, and helplessness. To address these issues, Thomas transformed the nursing home into a small Noah’s Ark complete with dogs, cats, birds, and other animals. These small though noisy bits of life proved a hindrance to staff at first, but their presence eventually instilled renewed purpose into the lives of the aging and even some dementia patients. Compared to standard nursing homes, prescriptions were half as likely to be needed and deaths dwindled by 15%. According to Thomas, the animals (however messy they were) breathed new life into the elderly. Caring for a special bird or taking one of the dogs for a stroll became something potent—a desire to live.  In 1908, the philosopher Josiah Royce uncovered the same principle in his work The Philosophy of Loyalty, which claims that “loyalty” to something outside of ourselves, a larger source of meaning, is necessary to a satisfied life. This is also true for those struggling with various forms of terminal illness. The preservation of purpose is more tenuous in cases of terminal illness or an incurable cancer, though. Palliative care expert Susan Block notes that end-of-life conversations are vital to establishing a patient’s desires in order to determine the best route of treatment. For instance, if a particular, unproven treatment has a great likelihood of disrupting a patient’s ability to think clearly, spend time with loved ones, or partake in other activities that give her life meaning, then it should be forgone as long as possible. Longer life isn’t always better or happier for the people idling their days in a chemo-induced stupor or constant discomfort.  A 2010 study from Massachusetts General Hospital compared the outcomes of 151 patients, half of whom received standard oncology treatment and half who were also tended to by palliative care specialists. These professionals seek to deliver patients from any undue suffering and cultivate as much normalcy in daily life as possible. The patients who received this palliative treatment ended ineffective chemo treatments sooner, withstood less pain, and lived 25% longer than the first group. Fostering comfort and preserving meaning actually diminished suffering and allowed for a longer more fulfilling life. Breathing without purpose is brutal. At the same time, cultivating that purpose can be just as difficult in the lives of terminally ill patients who require treatments that may impair their meaning. This is where the role of the physician becomes crucial and the purpose of medicine most meaningful—dying isn’t an end but a new lens through which to perceive meaning.

5. Medicine must look at death in order to nurture life. Not even doctors are immune to the staggering experience of witnessing a loved one dying. The author writes poignantly about his father Atmaram Gawande’s death. At his ill father’s bedside, the author practiced the advice he gives to other doctors. End-of-life conversations and hospice care are crucial to effective medicine that doesn’t simply extend a painful life, but rather creates a fuller existence. According to expert Susan Block, end-of-life conversations are transparent interactions between physician and patient in which the physician expresses the truth of a possibly heart-rending situation and endeavors to discern the patient’s ultimate aims along the way. Unfortunately, most doctors shrink beneath the weight of this responsibility. Sociologist Nicholas Christakis surveyed 500 terminally ill patients to analyze the particular way in which the doctor delivered their prognoses and found that 63% emphasized the higher (and least likely) survival time rather than the average. According to bioethicists Linda and Ezekiel Emanuel, doctors often fall into one of three categories in their relationships with patients: There’s the paternalistic doctor, the physician who tells patients what to do regardless of their questions or desires; the informative doctor who floods patients with a barrage of medical jargon and leaves the ultimately uninformed choice up to them; and the interpretive doctor, the one who provides patients with adequate information and personalized advice to make a wise decision. Modern physicians must break the mold of today’s information-laden doctors and become interpretive practitioners. Only then will patients grow equipped to make wisely-informed decisions about their life and their overall desires. In the case of Atmaram Gawande, he resolved to forgo a potentially paralyzing spinal surgery in order to continue practicing medicine, playing tennis, and spending time with loved ones for as long as possible. Though he was a doctor himself, he still needed to face the questions of his ultimate purposes for treatment in order to act most beneficially for himself. Not long after his eventual surgery and chemotherapy treatment, the author’s father decided it was time to stop—treatment had taken him as far as it was going to and he wanted the last bits of time for his loved ones and the things that carved meaning from the shape of his life. Contrary to a cultural misconception, hospice isn’t admitting defeat. Rather, it’s cultivating a span of time in which the aging and the dying may enjoy life as much as possible, free from oppressive, ineffective treatments that prevent them from living, and which refuse to acknowledge the inevitability of death. Hospice as a humane means to honor life is increasing throughout the United States, and in 2010, 45% of those who died did so in hospice care. Medicine is not a cure for death; sometimes, it seems to summon more suffering into the crushed lives of the ill and the aging. When doctors, patients, and culture alike accept the reality of death, then they can work together to alleviate the pain of the dying and usher comfort and meaning into their end.

6. Our lives are broken circles that need to be closed—the human brain requires a “dying role.” The illusion of infallible medicine corrupts the movement of life into death. Medicine can’t cure the process of dying no matter how hard we cling to it, push for the next treatment, and seek out the most distinguished doctors. All of that matters, but only when medicine is looked at as more than a simple means to extend life is it truly humane and beneficial. Oftentimes, patients live their last hours in an impersonal hospital, experiencing excruciating pain and inordinate suffering. The “dying role,” or the feeling that life has arrived at its proper ending with loved ones provided for and one’s overall purpose secured, is often forfeited for the sake of seemingly helpful medicine. But we need a fulfilling ending just as much as we require a meaningful life. According to the psychologist Daniel Kahneman’s work Thinking, Fast and Slow, people don’t measure experiences by averages but rather by what he terms the “Peak-End rule.” This rule asserts that when looking back upon a particular event, a person will gauge her experience of both suffering and happiness based upon its greatest “peak” and its inevitable “end.” We remember things not as a whole but as highlights and endings. Those arriving at the close of their lives deserve endings worthy of a meaningful life. They deserve to feel the circle of things close in upon itself peacefully and pleasantly, knowing that their existence spilled meaning into the world.  Modern medicine must be employed to this end to fulfill its purpose. Health and happiness aren’t determined by the length of one’s years; they can’t be counted on our fingers. Health and happiness are woven throughout the meaning we wrap our lives in—medicine that views every person as more than a cancer patient or an elderly person is medicine that sees through to the end of itself to serve our temporary, beautiful life.