Friday, January 8, 2016

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

Atul Gowande's Being Mortal: Medicine and What Matters in the End (Macmillan, 2014, 300 pages, $26.00/12.99) confronts each reader with an inevitability that must catch all of us: Death. Everyone is going there. From the moment we are born, it's where we're headed. No matter how much we live and strive to enjoy, make meaningful, explore, and understand our life, we're all headed to the end of what's knowable. Gawande has written a much praised and read exploration, handbook, and inspiration designed to help those facing their own mortality or charged with being responsible for the dignified end of life for their loved ones. This book poses several questions which we must answer as we head down this path:
  1. What is your understanding of the situation and its potential outcomes?
  2. What are your fears and hopes?
  3. What trade-offs are you willing and unwilling to make?
  4. What is the best course of action to achieve this understanding?
Simply put, answering these four questions will help structure the way a person approaches death and how family members can help. The book also stands as a beacon for medical practitioners, most of whom have not been trained or learned themselves in helping their patients find answers to these questions such that the they themselves can aid in answering the them rather than obstructing the solutions or striving endlessly to put off the inevitable.

Atul Gawande

Gawande, who is a McArthur genius award recipient and writes frequently for The New Yorker, is a general and thoracic surgeon practicing at Brigham and Women's Hospital in Boston as well as teaching at Harvard Medical School. In Being Mortal Gowande seeks to achieve several goals, and does so in an effective an entertaining fashion. He notes that changes in society have led to a move away from extended families living in the same home for a lifetime. When several generations live together, they are able to care for the aging at home, giving them the love and respect they have earned through their working lives. He tells stories about his own family, in India, as examples of a society that still functions in this way. In America, we've developed into a culture where children leave home to go out on their own, leaving death and dying in the hands of the medical establishment, rather than the home and family. He notes that the education of physicians, trained to fight ceaselessly to prolong life, has not traditionally focused on helping to ease people through end-of-life situations where the end is inevitable, but whose timing is not easily predictable. Gowande, a lively and interesting story-teller, uses case studies of families and care institutions to describe the changes developing in modern society with its increasing average age.

He describes some of the alternatives to the “old folks home” that have developed since the 1960's in response to changes in retirement patterns and the development of Medicare. He writes about a young rural doctor who developed the idea of assisted living as an alternative to nursing homes for the aging and aged. Other people people re-designed low income housing to allow aged people to maintain their independence longer while being in a setting where resident nurses and aides were on-site and professional medical care nearby. For people with greater means, residential life-care facilities have been developed. All these alternatives have, at their center, the goal of helping the aging to remain as independent as they can for as long as possible, while preparing them the slow (or not so slow) descent into disability or dementia. He bemoans the fact, that while we live in an aging society, the country has chosen, as a matter of policy, to allow the specialty of gerontology to whither on the vine as more glamorous and remunerative specialties have flourished.

Readers can use this book as a guide to thinking about and planning for their own end-of-life experience in order to make the most of it. As Gawande describes the aging process, everyone will experience increasing loss of mobility, the risk of injury from falling, the chances of debility from disease, all leading to increasing dependence and inability to care for one's self. Placing yourself in a position to experience as much comfort as possible as the process moves toward death is the goal. Reducing suffering and fear, finding ways to prepare, is challenging, but possible. Gowande describes the alternatives in graphic, but caring, fashion telling how the decline and death of patients has affected family members, physicians whose perspective is to continue fighting off death, and the patients themselves as, with the aid of family, friends, and medical personnel they seek to die with dignity and fortitude. While most people don't think of their doctors in terms of compassion, that's the word that best comes to mind for Gawande as he learns from his patients, the pioneers in gerontology he interviews, and elder care facilities he visits to introduce them to his readers.

Finally, Gawande describes Hospice as a way to approach the end with dignity in one's home under managed circumstances. Hospice emphasizes palliative care, i.e pain relief, and home care as one approaches death. The research has shown that in Hospice, people go to the hospital less often, when given the choice, and live longer. Palliative care seems to relieve stress and anxiety, relieving patients from continually fighting the illness. Gawande comments “ live longer only when you stop trying to live longer.” (pg. 178) He emphasizes the importance of advance directions concerning treatment, whether resuscitation is an alternative, how aggressive the treatment should be. He introduces an analogy comparing General George A. Custer, of Last Stand fame, with Robert E. Lee, as models for knowing when to fight and when to surrender. He redefines the role of the physician from insuring health and survival to working to enable well-being as death encroaches.

There are no easy answers to questions regarding death and dying. Gowande helps readers to think about their own deaths, and to engage in a process of preparing for it with grace and dignity. He talks more about easing suffering than he does about delaying death and curing disease in the elderly. These are not easy topics to read about in the abstract, let alone to seek to apply to one's own life. Nevertheless, the questions Gawande raises are of deep and abiding importance to those of us who are aging (that means everyone) and useful for thinking about death and preparing to face it. The earlier one thinks about these issues and makes plans to face them, the easier the days of decline are likely to be. Meanwhile, as we watch Gawande deal with his own father's decline as a physician and a loving son, we are brought into place where such thinking becomes not only possible, but desirable. Being Mortal: Medicine and What Matters in the End (Macmillan, 2014, 300 pages, $26.00/12.99) by Atul Gawande is a book that every reader should include in their library. I bought the book and read it on my Kindle App.