Being Mortal
Pictured here: Being Mortal with Naomi Shahib Nye’s Voices in the Air open to “Voices in the Air”
Being Mortal: Medicine and What Matters in the End (2014) is Atul Gawande’s deep dive into human mortality and end of life care. It is both insightful and moving, thought-provoking and, at times, like many compelling reads, uncomfortable. It is full of the sort of discomfort that feels necessary when considering mortality and all its implications. As a surgeon and public health writer, Gawande has a unique view of human mortality; one informed by medical school training, surgical practice, and extensive research. Ultimately, Being Mortal begs readers to recognize a simple truth: old age and death is not a failure or a health crisis; it is another step in life, one we all must face.
And yet, for over half a century, Western end-of-life care has viewed (and attempted to treat) the body’s natural decline as a medical problem in need of intervention. As such, we have failed to recognize the complexity of certain lost function, independence, and dignity in our current system. The result can be multi-generational traumatic circumstances with depressed elders and frantic, uncertain family members trying to do the best for their aging loved ones as they can. To say Being Mortal is a book we should all read is an understatement; our shared mortality insists we all find a copy. Now.
Gawande opens the book speaking from his medical training. He outlines, at length, the physiognomy of aging from graying hair to thinning bones. At the heart of Being Mortal is Gawande’s sincere desire that we accept death from old age as an unavoidable end rather than a medical failure. He also wants us to recognize that by not discussing or wishing to tolerate conversations about end of life, systems medicalize old age. Families suffer. Ultimately, debilitated elderly are confined to care facilities that make their final year(s) miserable.
Mortality is as much a part of life as birth, and yet we certainly do not celebrate it. In the States many people refuse to discuss it at all even with close family members. It is a fundamental truth that few openly accept and carefully consider before facing it as a crisis. As a result, many of us, doctors included, will do anything to postpone it and respond to it without taking the time to consider what each individual needs out of life. Gawande returns to the fundamental question he might ask a patient: what does a good day look like? Maybe it includes the physical prowess needed to take a daily walk or maybe it is as simple as reading a book in the sunshine. By asking this sort of question prior to end of life crisis, doctors and family members can support their patients and loved ones to make informed decisions about their end of life care. Being Mortal provides readers a catalyst for these conversations with ourselves, our families, and our physicians.
In Being Mortal, Gawande outlines the history of elder care in the US and other nations, and explores the roads that have led to our current retirement home system. Through all the stories he shares, stories of tragically young terminal patients, cancer-ridden aging friends, and the even his own father, a series of questions arise when we face difficult decisions about risky treatment, hospice care, and assisted living. These questions repeat throughout the book: what is your understanding of the situation? What are your fears and hopes? What trade offs are you willing to make what are you not? Ultimately, what is the best course of action to serve this understanding. These are the difficult questions most of us will happily sweep under the rug and refuse to face. As Being Mortal points out, however, by postponing those considerations, we often pass them on to our physicians and loved ones as end of life care is no longer a hypothetical conversation but a critical one.
As medical intervention and end of life care becomes more and more sophisticated, it is increasingly imperative that we all face our mortality openly and honestly. Books like Being Mortal can help guide us to the difficult considerations each of us will approach in our unique way. This isn’t a lengthy book, but it is certainly a big one in terms of the impact it might make on how we all approach death. As such, it is a book well worth the time, and possible discomfort, it takes to read it.
Bibliography:
Gawande, Atul. Being Mortal: Medicine and What Matters in the End. Metropolitan Books: 2014.
A Few Great Passages:
“This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals— from freeing up hospital beds to taking burdens off families' hands to coping with poverty among the elderly-but never the goal that matters to the people who reside in them: how to make life worth living when we're weak and frail and can't fend for ourselves anymore” (76-77).
“[O]ur driving motivations in life, instead of remaining constant, change hugely over time and in ways that don't quite fit Maslow's classic hierarchy. In young adulthood, people seek a life of growth and self-fulfillment, just as Maslow suggested. Growing up involves opening outward. We search out new experiences, wider social connections, and ways of putting our stamp on the world. When people reach the latter half of adulthood, however, their priorities change markedly. Most reduce the amount of time and effort they spend pursuing achievement and social networks. They narrow in. Given the choice, young people prefer meeting new people to spending time with, say, a sibling; old people prefer the opposite. Studies find that as people grow older they interact with fewer people and concentrate more on spending time with family and established friends. They focus on being rather than doing and on the present more than the future.” (93-94).
“Far from growing unhappier, people reported more positive emotions as they aged. They became less prone to anxiety, depression, and anger. They experienced trials, to be sure, and more moments of poignancy-that is, of positive and negative emotion mixed together. But overall, they found living to be a more emotionally satisfying and stable experience as time passed, even as old age narrowed the lives they led” (95).
“In the absence of what people like my grandfather could count on—a vast extended family constantly on hand to let him make his own choices-our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about” (108-109).
“Our lives are inherently dependent on others and subject to forces and circumstances well beyond our control. Having more freedom seems better than having less.
But to what end? The amount of freedom you have in your life is not the measure of the worth of your life. Just as safety is an empty and even self-defeating goal to live for, so ultimately is autonomy” (140).
“All we ask is to be allowed to remain the writers of our own story. That story is ever changing. Over the course of our lives, we may encounter unimaginable difficulties. Our concerns and desires may shift. But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties” (140-141).
“The battle of being mortal is the battle to maintain the integrity of one's life—to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe their job is not to confine people's choices, in the name of safety, but to expand them, in the name of living a worthwhile life” (141).
“In the end, people don't view their life as merely the average of all of its moments-which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens.
Measurements of people's minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life may be empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than our-selves. Unlike your experiencing self-which is absorbed in the moment-your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. Why would a football fan let a few flubbed minutes at the end of the game ruin three hours of bliss? Because a football game is a story. And in stories, endings matter” (238-239).
“Technological society has forgotten what scholars call the ‘dying role’ and its importance to people as life approaches its end. People want to share memories, pass on wisdoms and keep-sakes, settle relationships, establish their legacies, make peace with God, and ensure that those who are left behind will be okay.
They want to end their stories on their own terms. This role is, observers argue, among life's most important, for both the dying and those left behind. And if it is, the way we deny people this role, out of obtuseness and neglect, is cause for everlasting shame.
Over and over, we in medicine inflict deep gouges at the end of people's lives and then stand oblivious to the harm done” (249).
