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This intelligent and compelling book invites us to evaluate the losses pertaining to “modern death” and to consider better ways—whether from the past or in the future—to care for the dying, their families, and all care-givers.   
            
Some chapters, such as “How Life (and Death) Were Prolonged,” are historical, describing changes in inoculations, living conditions, and medical care that extended the human life span but also changes in dying, now often prolonged by technology. Another chapter, “How We Learned Not to Resuscitate,” relates how CPR, initially lauded and popularized, is now widely understood as futile care, especially in older people. Warraich discusses various attempts to define death (brain-based, heart-based, American Bar Association, Harvard Criteria, Uniform Determination of Death Act, even NASA) and some of the issues that still remain.   

Other chapters are more physiological:  “How Cells Die” explains natural processes of cell death (necrosis, autophagy, and apoptosis). Most non-medical readers haven’t heard of these and perhaps some medical personnel as well. Unaware of them as regular and usual processes, we resolutely expect people to live some four-score and ten, perhaps even more. The next-to-last chapter, “When the Plug is Pulled” discusses “terminal sedation” (a legal dosage that eases pain but is not strictly speaking euthanasia or murder) and statutes that allow for assisted death and removal of life-sustaining machines. The Nancy Cruzan case and others illustrate many difficulties. (Cruzan was in a persistent vegetative state and supported by a feeding tube. A 1990 U.S. Supreme Court 5-4 decision allowed the removal of the tube.) Warraich argues further for “patients’ right to demand and acquire the means to end their suffering with the aid of a physician” (p. 263).              

Lack of resolution of these difficulties leads to problems for families of the dying and all medical personnel attending them, especially in ICU situations. Living wills are often of no help and “the end of life has become a battleground” (p. 211). He argues that surrogate roles for decisions at the end of a life often do not represent what the patient actually wanted because the surrogate's values may be different from the patient's and family members may not reach agreement on decisions. He concludes, “All in all, overinvolved family and underinvolved doctors unsurprisingly make for a particularly caustic combo” (p.214).                      

In “When Death Transcends” we read that spiritual and religious matters are often ignored in medical settings. Such resources, however, “may be the only means that patients have of finding comfort” (p. 148). Warraich surveys various religions, including his own, Islam. This is one of the longest chapters in the book and carefully considers the wide range of faiths people have and the regrettable lack of training for doctors in this area.            

Warraich concludes, “Death needs to be closer to home, preceded by lesser disability and less isolation” (p. 278). For deaths to be “truly modern,” we need to push past taboos and misunderstandings about death. 

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The film enters late into the lives of Anne and Georges, a Parisian couple apparently in their 80s, apparently long married, and apparently retired music teachers. Maybe they still teach music, and maybe they still play, based on the important place a grand piano is given in the grand living room of their apartment. Their daughter, Eva, is a working musician and is married to one as well. When Georges and Anne sit together in the living room, the controls to the stereo system are never more than an arm’s length away. This family is serious about music; they love music. But, their love of music is not the love of the movie title, “Amour.” Amour is the love between Anne and Georges, and the forms this love takes. 

We first see the amour of Georges and Anne in their quotidian activities. They eat breakfast together at the small table in the cramped kitchen. They sit across from one another—or one of them lies down on the adjacent couch—and read to each other from the paper or talk about various subjects, like music. They have been doing this for decades, and probably would for decades more, but that isn’t likely, and we see why soon. 

While having their breakfast one morning, Anne becomes unresponsive to Georges while looking him straight in the eye. She eventually comes to and goes about her business as if nothing happened and doesn’t know what Georges is talking about when he describes the incident. She probably had a transient ischemic attack—a warning that a stroke may be coming—and as a result, had surgery to clear an occlusion from her carotid artery to prevent a stroke from actually occurring. However, something goes wrong in the hospital and Anne suffers a stroke there nevertheless. She returns home with some paralysis on her right side. The form of amour changes. Now the quotidian activities involve Georges administering care to Anne: he sees to her toilet, washes her hair, cuts her food, reads her newspaper articles, and helps her walk from one spot to another in the apartment when he’s not pushing her in a wheelchair. During a moment when Georges and Anne are in their customary chairs in the living room, Georges says to her, “I’m so pleased to have you back.” To which Anne responds, “Please never take me back to the hospital, promise?” 

But when Anne has another stroke, Georges takes her back to the hospital. She returns home having lost most of her ability to move at all, she can only eat or drink with considerable difficulty even with assistance, she can’t communicate verbally to any extent, and she wets herself. Georges adds feeding her and exercising her arms and legs to his established routines of bathing her, reading to her, and telling her stories. Amour has taken the shape of getting her through the days with great effort and later with help from nurses.  

Anne wants no more of her life despite Georges’ efforts and pleas. His daughter argues with him about the care her mother needs. The nurses can’t administer care to Anne in a way he expects. Anne does not want her daughter to see her as she is. She cries out for her own mother. She won’t take water or food. She is in pain. Georges is left with only options that test the extreme boundaries of amour.

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Australian writer Cory Taylor was diagnosed with untreatable melanoma at the age of 60.  In a few short weeks she wrote this memoir, exploring what she was feeling and what is missing in modern medical care of the dying.  She died at the age of 61, a few months after this book appeared in her native country.  

The book has three parts. Part I, Cold Feet, starts right off discussing a euthanasia drug purchased online from China. Taylor’s melanoma has metastasized to many parts of her body, including her brain. It was first diagnosed in 2005, a malignant mole behind her right knee. In the decade of her cancer, she has tried three drug trials, thought about suicide, and received palliative care. She has harsh words for doctors who don’t mention death, a psychologist who doesn’t help her “Adjustment disorder,” and medicine in general that sees death as a failure.      
       
Taylor feels anger, sadness, and loneliness. She finds comfort and camaraderie in a group called Exit, where there’s frank discussion about death. She writes, “We’re like the last survivors on a sinking ship, huddled together for warmth” (p. 14). She has neither religious training nor interest in it. She became a writer late in life, and now she sees a clear purpose for her “final book.” She writes, “I am making a shape for my death, so that I, and others can see it clearly. And I am making it bearable for myself” (p. 31).  

Although scared and suffering, she is reluctant to commit suicide because of the impact on her husband, two sons, and friends. Dying, she writes, “is by far the hardest thing I have ever done, and I will be glad when it’s over” (p. 49).

Part II, Dust and Ashes, describes her earlier life with her mother and father. Her parents were unhappy together and eventually divorced. In her life review, Taylor searches for meaning in the influences on her life. Her family moved often in Australia, also to Fiji and Africa. She feels rootless herself, traveling to England and Japan. Both of her parents die with dementia; she was with neither one at their ends.  
   
Part III, Endings and Beginnings, goes further back to her childhood. She reflects on an idyllic time in Fiji, her discovery of the power of language and writing, and various trials of growing up. She worries that she wasn’t vigilant enough in checking her skin, thereby allowing her disease to become fatal. She feels autonomy in having the Chinese euthanasia drug, but her life is clearly closing in. She says she weighs less than her neighbor’s dog. The last page of the book imagines her death as a cinematic montage, ending with “Fade to black” (p. 141).  

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Walter Mosley writes in various genres but is probably best known for his mysteries. His 2010 novel, The Last Days of Ptolemy Grey, could be considered another one of his mysteries, but the mystery plot takes a secondary role. Featured more prominently is the struggle the main character, Ptolemy Grey, has with dementia.   

The reader first encounters Ptolemy Grey when he is 91 years old and living alone in an apartment he has inhabited in South Central LA for more than 60 years. Both he and the apartment are in appalling shape. The apartment is cluttered, disorganized, and dysfunctional—as is his aging brain. He knows his mind is failing and seems to him as if it “had fallen in on itself like an old barn left unmended and untended through too many seasons.” (p.153)

Throughout the novel, Mosley presents aspects of dementia and some of its oddities. For example, while Ptolemy is riding on a bus through his town, certain sights trigger clear memories from his childhood 80 years before. At the same time he is unsure where he is going or why. Mosley also shows how people can possibly realize they are slipping into dementia, for example, when Ptolemy stops talking to a friend once “he could see in her eyes he wasn’t making sense.” (p. 122)

Ptolemy’s great-grandnephew Reggie provides him with the assistance he needs to barely maintain his lonely existence in squalid conditions. When Reggie dies, a new person comes into his life. Robyn, a 17-year-old orphan living with Ptolemy’s grandniece, begins to straighten out his apartment and then his mind.    

As Robyn gets Ptolemy’s apartment more organized and functional, Ptolemy’s mind starts to get more organized and functional as well, but only a bit more. Unsatisfied with his progress, Robyn takes Ptolemy to a physician who has an experimental drug for dementia. Ptolemy is told that if he takes the drug he will regain his mental acuity but probably not live more than a few weeks, or months, at best. Without hesitation he takes the drug—“I wanna make it so I could think good for just a couple a mont’s, Doc” (p. 126)—and rapidly regains many memories and mental capacities. During the time he has with his newfound mental agility, Ptolemy is able to make good on a commitment from his childhood and to solve the mystery of Reggie’s death. While the experimental drug enables Ptolemy to wrap up his business, it also produces a rather violent end to his life.

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The author, an experienced surgeon, believes that we will be less frightened by the prospect of death if we understand it as a normal biologic process. He points out that 80 percent of deaths in this country now occur in hospitals and are therefore "sanitized," hidden from view, and from public comprehension. He describes the death process for six major killers: heart disease, stroke, AIDS, cancer, accidents/suicide, and Alzheimer's disease.But the power of the book is in its intensely personal depiction of these events and in the lessons which Nuland draws from his experiences. The message is twofold: very few will "die with dignity" so that (1) it behooves us to lead a productive LIFE of dignity, (2) physicians, patients, and families should behave appropriately to allow nature to take its course instead of treating death as the enemy to be staved off at any cost. Only then will it be possible for us to die in the "best" possible way--in relative comfort, in the company of those we love/who love us.

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Atul Gawande’s Being Mortal is both ambitious and synthetic, qualities that well suit his difficult subject, death.  In Western culture, there are taboos against death because it fits neither into post-Enlightenment notions of progress and perfection nor into medical notions of control, even domination of human biology. A surgeon and an investigator, Gawande draws on his patients, his family, and travels to various hospitals and other caregiving places in order to confront death and see how approaches such as hospice and palliative care can improve our understanding, acceptance, and preparation for death.

Gawande has harsh words for contemporary medicine, the supposed caregiver for the dying and their families.  Relying heavily on technique and industrial models, it ignores the deep needs of the dying and provides, instead, versions of “warehoused oblivion” (p. 188), for example long, futile stays in ICUs.

As opposed to traditional societies like India, Westerners prize the independence of individuals, a status that is, of course, never permanent. In the chapter “Things Fall Apart,” Gawande describes how longer lives are now the norm but they include chronic illnesses and inevitable decline in vitality.  Our deaths are now routinely in hospitals, not at home, and often extended—sometimes brutally—by technical support and unwillingness of doctors and families to stop aggressive treatment.       
       
Also, sadly, there are fewer and fewer geriatricians at a time when there are more and more elderly.  A good geriatrician takes a long time with each patient, is not well paid, nor does s/he do income-generating procedures. Worse yet, some training programs are being discontinued.  

Gawande illustrates his ideas with case studies of patients and describes, from time to time in the book, the elderly journeys of his grandmother-in-law and his own father.  These passages make vivid the abstract ideas of the book. But it’s not just elderly patients who face death: health calamities can come to anyone, for example, a 34-year-old pregnant woman found to have a serious cancer. Various treatments are tried without success, but family and doctors act out “a modern tragedy replayed millions of times over” (p. 183) of a medically protracted death. Finally her mother calls a halt to treatment.
               
Family members often bear a heavy load in caring for a sick elder, but many nursing homes are often worse, designed for control, not support of the patients. 

The chapter “A Better Life” describes the first in a series of places that offer much improved settings for the elderly, with birds, animals, gardens, and, in general, richer lives that have a sense of purpose.  Gawande describes hospice care, palliative care, and advanced directives (including Do Not Resuscitate orders) as improvements needed to break the norms of “treat at all costs.” The old roles of Dr. Knows-Best and Dr. Informative need to give way to physicians and others who talk with patients and families about their values, their wishes for the last days, and their preparations for death. In short, aggressive treatment should no longer be the “default setting” for hospital care.     
        
The book ends with a dozen moving pages about the death of Gawande’s father. The “hard conversations” have clarified his wishes, and hospice care has provided “good enough” days.  Pain control has done well. Then, finally, “No more breaths came.” The family travels to India to spread his ashes on the Ganges. 

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