Sunday, November 2, 2014

Being Mortal

Being Mortal: Medicine and What Matters in the End
Atul Gawande  (2014, Metropolitan Books)

    Atul Gawande is a surgeon, a writer, and, lucky for us, a perpetual student. What he knows about death and dying, he did not learn in medical school. In fact, the attitudes and practices of medicine often make aging and dying harder these days; since three out of three people die, Gawande is hoping we can learn to do it better.

    Geriatric care is one area with vast room for improvement. The care of the elderly  is not a glamorous or highly paid field, and there are far too few doctors (or nurses or social workers) taking it up. This is partly because of the perverse incentives of our insurance system, which would rather pay for x-rays and blood tests than for conversations about nutrition and exercise. Gawande thinks it’s also because people go into medicine to solve problems, and geriatric patients often have problems that can’t be solved. “What geriatricians do–bolster our resilience in old age, our capacity to weather what comes–is both difficult and unappealingly limited.” The results of such care can be dramatic, with far fewer negative side effects than drugs and operations, but it takes time, slow time, that doctors generally cannot spare.

    Nursing home care is another case of the medical model failing to give satisfaction. Gawande delves into history: for most of the human era, the few people who lived to old age were cared for by family or in community almshouses. Since the middle of the last century, people leaving hospitals when the hospitals couldn’t cure them have mostly been moved to nursing homes, where they’re treated as helpless patients. It’s no wonder people find them lonely and depressing.

    Gawande looks at several groups of people trying to work out a third way, that would relieve the burden on wives and daughters, yet feel more home-like, and give people an opportunity for a more meaningful life.  The original model of assisted living has been diluted, in many places, but the impulse is sound, to balance safety and autonomy. We don’t want people to fall and break their hips; but keeping them in wheelchairs, as though they already have broken hips, is a lousy solution.

    Gawande comes to a conclusion that challenges medicine at its foundation: “ people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives–resisting the urge to fiddle and fix and control.” Patients, families, and doctors frequently wind up on a treadmill of treatments, side effects, and complications that no one knows how to stop, leading to a death without comfort or consolation.

    Hospice care tends to be seen as a last resort, implying that doctors have given up on a patient, but Gawande uncovers a more nuanced reality. Again, it is a matter of altered perspective, giving greater weight to what the patient actually finds meaningful, whether that’s visiting grandchildren, watching baseball games, or drinking beer.

    Most of us are not doctors, but we will surely not get through life without facing the question of how much treatment is too much. “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.”

    I hope this book starts a lot of conversations, both systemic and personal.

Email edition, November 2014