Summary:
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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