Book review: Being Mortal

It has been said that most people in the United States spend more time planning their next vacation than they do planning how they want to live the last years of their lives.

While we go to great lengths planning for retirement—starting at an early age and usually at the beginning of one’s career—we rarely, if ever, give any thought to how we will live out our final years.

How we might plan our later years is the subject of the book I have chosen for this review.

It is a 2014 book titled Being Mortal: Medicine and What Matters in the End. It is available in soft cover (263 pages) and electronically.

The author is Dr. Atul Gawande, a surgeon and a staff writer for The New Yorker, as well as a professor at Harvard Medical School.

According to the author, scientific advances have turned the process of aging and dying into medical experiences to be managed by health care professionals, such as hospitals and nursing homes, which many times appear unprepared to deal effectively with these issues.

The author also points out that old age has changed from being a rarity in the past to its current state where, in 2014, 14 percent of the U.S. population was over 65 years of age and China is the first country in the world with more than 100 million elderly people.

In addition to living longer, the elderly are living more independently and away from their children. Unfortunately, this independence cannot be maintained forever and, sooner or later, all of us who are fortunate enough to live into “old age” will not be able to function strictly on our own without some kind of outside help. However, medicine, according to the author, seems to have failed to agree on just what kind of outside help is best for the elderly. Equally worrisome, and far less recognized, medicine has been slow to confront the very changes that it has been responsible for, or to apply the knowledge it has to making old age better.

The job of doctors, according to the author, is to support the quality of life, which means providing as much freedom from the ravages of disease as possible and enabling the retention of enough function for active engagement in everyday life. He also feels that most doctors treat the disease and figure the rest will take care of itself. But, if it does not, such as when a patient becomes infirm and goes to a nursing home, the doctors assume that it is then no longer a medical problem.

Again according to the author, the very old usually do not fear death but they fear what happens to them short of death, namely, losing their hearing, their memory, their best friends and their way of life.

Dr. Gawande shares several case studies of not just elderly patients, but elderly patients with incurable terminal diseases and illnesses and the choices presented to them.  The choices are frequently various treatments which are not really meant to cure the disease, but to extend their lives. One such case study was that of his father, a urologist, who developed terminal cancer and had to make treatment choices that did not involve the quantity of his life, but the quality of his life during this incurable illness preceding his death.

There are several chapters in the book about nursing homes, including their history, evolving from poor houses to hospitals to what we now call nursing homes. These facilities were originally created to make more hospital beds available.

This description also sheds light on the rigidity of nursing home life, such things as being told what to do, when to do it, when to eat, what to wear, when to sleep, when to bathe, and the succession of roommates who are never chosen with any input from the patient. In other words, the aim of present day nursing homes, according to the author, is caring and safety, but includes nothing about making a patient’s remaining life worth living.

The book also explores “assisted living,” which it considers an intermediary station between independent living and life in a nursing home. It also discusses several fairly new concepts of care, including “green houses” and “living centers with assistance,” where resident patients have control of heat, air conditioning, meals, pets, clothing, personal care and medications, but can summon help at any time they need it. Ordinarily, “green houses” are small with no more than 12 residents.

Finally, the book discusses hospice care for terminal illnesses and diseases, at any age, as a possible choice to make life better at its end. With hospice care, the time of death in most cases is about the same as for those who continue with more medical tests, treatments and surgeries, but end of life costs are much lower. In 2010, 43 percent of Americans died in hospice care rather than in hospitals or nursing homes, and more than half of those receiving hospice care were at home while the remainder died in an inpatient hospice facility or a nursing home.

The underlying theme of this book appears as a part of its epilogue. Medicine has been wrong because it thinks its job is to ensure health and survival. But, the author points out, it is larger than that; the job should be to enable wellbeing, making lives more meaningful in old age and during terminal illnesses, and maintaining the integrity of one’s life.