In Being Mortal:
Medicine and What Matters in the End, Atul Gawande, M.D., makes a powerful
case for improving quality of life in our final years. Drawing on scientific
studies, he points out that people facing the finitude of life want meaning. In
sharp contrast are case studies of terminally ill or simply aging people caught
in a medical system focused on curing what in reality cannot be cured. This
results in a person’s last days or years being painfully full of treatment side
effects that prevent him from enjoying what matters most to him.
Gawande begins the journey that became this book by
questioning whether his medical training had adequately prepared him to help
patients with their physical decline and mortality. He looks at how differently
a geriatrician and a “regular” physician approach an elderly patient. Older
folks are clearly better served by the geriatrician considering the whole
person with multiple irrevocable issues natural to aging. Yet this field is
lower paying than other medical fields, and not nearly enough doctors train for
it.
To begin with, assigning aging to our medical system, as we
do in the United States, is a core problem. Gawande posits that it doesn’t belong
there. Aging is not about only safety and survival, medicine’s focus. He sets
out on a journey to explore how we might change and until the system changes,
how he might change to give his patients more control, options, and meaning.
“What makes life worth living when we are old and frail and unable to care for
ourselves?” [page 92 in my edition]
In conversational style he recounts stories of his elderly relatives,
his own patients, and other people with terminal cancer. He looks at the quality
of their last days/years when medicine railroads them into trying every
procedure and medicine available to prolong their lives, or requires safety
above all. He contrasts that with the last days/years of people who weigh their
risks, decide what matters most to them (eating chocolate ice cream, visiting
with friends, as examples), and choose the medical options that best enable
that outcome. He adds to these anecdotes the results of scientific studies on
the subject and the wisdom of hospice experts.
Gawande’s journey brings him to understand that the
questions he asks a patient facing death are critical. One doctor-patient
relationship style is the doctor telling the patient what to do. On the other
end of the spectrum is an informative style in which the doctor explains
options. Gawande discovers, “In truth, neither type is quite what people
desire. We want information and control, but we also want guidance. The
Emanuels [medical ethicists] described a third type of doctor-patient
relationship, which they called ‘interpretive.’ Here the doctor’s role is to
help patients determine what they want. Interpretive doctors ask, ‘What is most
important to you? What are your worries?’ Then, when they know your answers,
they tell you about the red pill and the blue pill and which one would most
help you achieve your priorities.” [page 201] A doctor’s time and words matter.
Gawande begins to move from informative to interpretive in his personal
doctoring style. This changes choices for both patient and physician.
This book evoked a range of emotions as I read it. I was
fascinated to learn the history of nursing homes and assisted care facilities.
I felt excited to hear of facilities whose founders really thought outside the
box in order to give more meaning to residents’ lives. Maybe I could find one
of these places when the time comes for me. My mother’s nursing home does many
things to enrich residents’ lives, and I feel glad to know this. Reading this
book also helped me trust my gut sense of how to keep my mother from being
railroaded by the medical system. I felt sobered learning the devastating
trials of patients cited in the book. What difficult choices they had to make.
I felt sad for them and their families. I felt vulnerable and oh so mortal. I
felt heartened to see instances of the human body triumphing and persevering,
at least temporarily, against unbelievable odds. I felt tickled by the sweet
simplicity of people’s last requests. I felt awed by the sophistication of
modern medicine. And I felt like jumping up and down and cheering for the profound
beauty of hospice care.
Atul Gawande takes an uncomfortable topic, end of life, and
makes it interesting. I recommend this book for anyone pondering life’s
finitude—measuring his horizons in the here and now—and for anyone in any
medical field. Gawande’s scientific sources for Being Mortal: Medicine and What Matters in the End are included in
a bibliography.
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