BEING MORTAL –by Dr. Atul Gawande
Medicine and What matters in the End
“Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone.” Dr. Atul Gawande in his path breaking book on Geriatrics and Palliative Care says “We have been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive.”
In what I consider as a deeply moving book, Gawande stresses on the need for a doctor to accept the reality of mortality and accordingly make it a focal point in the way he treats the dying. In the Introduction he says that he remembers discussing mortality during a seminar, spending more than hour on Leo Tolstoy’s classic ‘The Death of Ivan Ilyich’ (I have discussed this book in one of my earlier posts on ‘A Dignified Exit’). Gawande quotes Tolstoy “What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo treatment and something very good would result.” He says that they as medical students saw it, the failure of those around Ivan Ilyich to offer comfort or to acknowledge what is happening to him, was a failure of character and culture. He admits that within a few years of surgical training and practice, he encountered patients forced to confront the realities of decline and mortality and that it did not take him long to realize how unready he was to help them.
The book is replete with the author’s confrontation with terminally ill patients, the aging and dying. The book traces the slow development of palliative care from Nursing Homes to Hospices to Assisted living.
This book disturbs you. It lays bare the reality of aging and increasing dependence. In the chapter ‘Dependence’ Gawande says “It is not death that the very old tell me they fear. It is what happens short of death – losing their hearing, their memory, their best friends, their way of life.” He says we do not think about the eventuality that most of us will spend significant periods of our lives too reduced and debilitated to live independently. As a result, most of us are unprepared for it.
With the changes in the family structure gravitating towards splinter groups the isolation and dependence of the aged has become acute. Nursing Homes and Hospitals where doctors and nurses more bothered about continuing procedures to check whether there are means of extending life even when they know that the patients has passed beyond such a stage only end up in extending the suffering of the patient.
Gawande, argues that quality of life is the desired goal for patients and families. He talks about more socially fulfilling models for assisting the infirm and dependent elderly. It is in this context that he outlines at various points in the book about hospice care to ensure that a person's last weeks or months may be rich and dignified. Hospice includes palliative care for the incurably ill given in such institutions as hospitals or nursing homes, but also care provided to those who would rather spend their last months and days of life in their own homes. He also describes Assisted Living as another fulfilling way of taking care of people with disabilities.
Referring to a book ‘The Philosophy of Loyalty” written by a Harvard Philosopher Josiah Royce, Gawande says that Royce wanted to understand why simply existing – why being merely housed and fed and safe and alive – seems empty and meaningless to us. What more is it that we need in order to feel that life is worthwhile? The answer he believed is that we all seek a cause beyond ourselves. This was to him, an intrinsic human need. The cause could be large (family, country, principle) or small project or the care of a pet. The important thing was that in ascribing value to the cause and seeing it as worth making sacrifices for, we give meaning to our lives meaning.
The book details about the efforts put in by individuals to find ways and means of improving the quality of life of the old and infirm, a number of them from their own experiences of tending to an aged parent or a spouse.
But the most telling part of the book is Dr.Gawande’s own account of handling the final stages of his father. The ending part of the book where he describes his father’s final days is intense and moving. In the beginning of the book he talks about his grandfather who lived till the age of a hundred and ten years and ultimately passed away surrounded by a large family in the midst of the people he loved and in his home. He says “My father’s father had the kind of traditional old age that from a Western perspective, seems idyllic” He continues “But in my grandfather’s world, how he wanted to live was his choice, and the family’s role was to make it possible”.
Despite having spent the entire part of his life in the US, born and bred up there, his father (a doctor himself) having migrated much earlier, Dr. Gawande comes to immerse the ashes of his father in the Ganges as per his wish –
“It’s hard to raise a good Hindu in small town Ohio, no matter how much my parents tried. I was not much of a believer in the idea of gods controlling people’s fates and did not suppose that anything we were doing was going to offer my father a special place in any afterworld. The Ganges might have been sacred to one of the world’s largest religions, but to me, the doctor, it was more notable as one of the world’s most polluted rivers ------ Yet I was still intensely moved and grateful to have gotten to do my part. For one my father wanted it, and my mother and sister did, too.”
Atul Gawande is a fantastic writer and has your attention till the end. More importantly he has touched on a subject that is the final anxiety of our existence.
About the Author
Atul Gawande is the author of three bestselling books: Complications, a finalist for the National Book Award; Better, selected by Amazon.com as one of the ten best books of 2007; and The Checklist Manifesto. He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for the New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Director of Ariadne Labs, a joint center for health system innovation, and Chairman of Lifebox, a charity making surgery safer globally. He lives with his wife and three children in Newton, Massachusetts.- Amazon