Being Mortal by Atul Gawande is subtitled, Medicine and What Matters in the End. It is a book that is scientific, humanistic, and philosophical. The subject is how to deal with death. As a surgeon, Gawande brings a special perspective to bear on this topic because, as he illustrates, we in the U.S (and the West in general) have pathologized death. This is to say that we treat death as a medical issue, something we can treat and put off and perhaps even defeat.
Gawande argues that there is more to death than thwarting it, postponing it, or ignoring it by warehousing it in nursing homes where the corridors are lined with aged, infirm men and women in their wheelchairs.
He offers many compelling case studies that illustrate ways to provide better end-of-life care than simply trying the next exotic medical technique or pharmaceutical. He describes nursing homes that are more like homes than hospitals. He examines the statistical facts about hospice programs that often prolong and improve life better than desperate measures.
None of us likes to talk about death or imagine our demise or put our affairs and relations in order, and the worst time to do any of this is after receiving a grim diagnosis of cancer, heart failure, or some other fatal malady. Gawande can’t overcome this, but he does show ways in which end-of-life conversations can take place that focus on the priorities and quality of a given life as opposed to the protocols and pretensions of advanced medicine.
This isn’t a book that damns medicine. Medicine is a wonderful thing that offers cures in so many ways that it couldn’t be called into question except in this particular case: when death is almost certain, regardless of medical measures, how should the doctor, patient, and family proceed?
Gawande advances the argument, compiled by many experienced practitioners he has studied, that the most important thing to do when dealing with a dying person is to ask questions and listen, not push answers and talk. He notes that when we ship our mortally ill to hospitals, we sometimes rescue them, but in many, many cases we divorce them from the very stuff of their lives, meaning their familiar surroundings, their loved ones, their little pleasures, and their memories.
This is truly a profound book that reflects wisely on an issue the United States (and the West in general) has not come to terms with, although promising initiatives have been taken all over the country. When there is no reasonable expectation of survival, isn’t it best to focus not on the length of time remaining but rather on the quality of time at hand?
For those of us who have dealt with parents or loved ones who have died, this book speaks to a great deal of anguish. One of the maddening things about dying when you are old is that often you die of many things at once. This sometimes is called systemic collapse. That means that the bowels stop functioning and the blood stops flowing and the nerves stop working and the lungs stop pumping air, and everything becomes jumbled–what do you deal with first, second, third? When do you recognize that palliative care, which is care focused on minimizing suffering, is better than curative care?
Toward the end of the book, Gawande emphasizes the need for every individual to come to terms with the end of his/her life’s narrative, to find an ending appropriate to his/her values and responsibilities and aspirations. Medical schools too often fail when it comes to the meaning of existence; experienced doctors don’t know how to confront the dying on the dying’s terms, not on the terms established by their training. In this book, Gawande offers a different approach, one he has observed acutely and experienced just as acutely in losing his father. Again, ask, don’t tell; listen, don’t talk; try to find a way to do for the patient what the patient really wants in his/her final experience of life. A side benefit to this approach is that six months after someone passes away, the survivor’s are less likely to feel guilty and depressed because they know they forced senseless medical treatment on a loved one that made things worse, not better, in the final days of life.