“I learned about a lot of things in medical school, but mortality wasn’t one of them.” So begins Being Mortal, Atul Gawande’s fourth and most ambitious book.
All of Gawande’s prior books – Complications, Better, and The Checklist Manifesto – were beautifully crafted, lyrical, and fascinating, and all were bestsellers that helped cement his reputation as the preeminent physician-writer of our time. Each blended Gawande’s personal experience as a practicing surgeon with his prodigious skills as an author and journalist. They took readers behind the curtain of the hospital and the operating room, revealing much about some very important matters, like medical training, quality improvement, patient safety, and health policy.
But they were only partly revealing of Gawande himself. He told us what we needed to know about his thoughts and biases in order to make his points, but no more. Being Mortal is Gawande’s most personal book, and as such it reaches a level of poignancy that surpasses the others. Mind you, it’s not an easy read, it’s a bit dull in the early going before it hits its stride, and it has an attitude: Gawande’s indictment of modern medicine’s approach to aging and dying is pointed and withering. But, even more than his other books, this one matters deeply.
As you likely know, Being Mortal is a treatise on how American society has medicalized the aging and dying process, mostly to the detriment of older people. Befitting its topic, there are layers of complexity here. For those of us who have been lucky enough to practice in environments in which hospice and palliative care services are readily available, the book is a useful reminder of things we already know, enlivened by Gawande’s masterful storytelling. In this category, I’d place some of the crucial elements of discussing bad news with patients and eliciting their preferences: the importance of listening more than talking; of focusing on patients’ goals and fears rather than on whether they want CPR or other specific interventions; of using certain phrases, such as “I wish I could…” (rather than, “There’s nothing I can do…”) and “I am worried…” (rather than a cold recitation of bad news); of how crucial it is to involve hospice and palliative care specialists at the appropriate times.
Gawande’s discussion of the tensions physicians face when discussing options with patients is particularly thoughtful. He rejects old-style paternalism, of course, but considers the modern approach of simply providing patients with facts and alternatives (“Dr. Informative”) equally egregious. As always, Gawande’s humility regarding his own struggles – humility that is particularly disarming when offered by such an admired figure – helps the reader understand that these are not easy matters, but that it is possible to improve. Ultimately, through a series of wrenching encounters, Gawande comes to learn that the best approach is a middle ground in which the physician solicits patients’ goals and preferences, then suggests courses of action that are in sync. [One story in the book, about a young woman who learned she had metastatic lung cancer while pregnant, was previously published in The New Yorker, and I wrote about it here, in a blog highlighting Gawande’s exceptional writing skills.]
I found two portions of the book to be particularly memorable and eye opening: his dissertation on nursing homes, and his discussion of his father’s terminal illness.
He recounts the evolution of the modern nursing home, dispiriting places in which America warehouses its old and frail. Prizing independence above all else, our society’s view of successful aging is of the fit septuagenarian on the golf course or in the yoga studio. Which is fine until the body begins to fail, at which time the “independent self” movement provides no obvious humane path for one’s final years – years that have been stretched out because of medical progress, as fewer people now drop dead of heart attacks and strokes but instead wither from the ravages of chronic diseases, cancer, and aging itself. “Lacking a coherent view of how people might live successfully all the way to their very end,” Gawande writes, “we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.”
A Gawande trademark is the way he focuses on the particular to bring out the general. For example, his section on the aging process is cringe-worthy but immensely effective. “Consider the teeth,” he admonishes, and then he catalogues the havoc that aging plays on our dentition: gums inflamed, blood supply atrophied, saliva petering out, and jaw muscles slackening. Even as our teeth soften, other body parts harden, including the aorta (“When you reach inside an elderly patient during surgery, the aorta… can feel crunchy under your fingers”) and the brain, which both hardens and shrinks, allowing it to rattle around inside the skull. None of this is fun to contemplate (he quotesPhilip Roth: “Old age is not a battle. Old age is a massacre.”), but that is precisely the point: Gawande is asking, even begging, us not to avert our eyes from this reality.
Rather than telling a simplistic but misleading story of how assisted living and other advances have made the aging process blissful, Gawande provides us with the history of the assisted living movement, with real advances accompanied by some daunting setbacks. He profiles several innovators – people who did their best to improve things but whose ideals were partly undermined by inertia, finances, the medicalization of aging, and the relentless focus on safety, a soul-sapping pursuit characterized by rules, restrictions, and infantilization.
One improbable innovator, Keren Wilson, built one of the nation’s first assisted-living facilities, in Oregon. Her goal was to create, for the older person losing independence, something that was more home than institution. Her experiment was a grand success, writes Gawande, until developers began “slapping the name [assisted living] on just about anything.” Another innovator, an iconoclastic physician named Bill Thomas, created a nursing facility that doubled as a menagerie, filled with dogs, cats, and birds. The joy of the residents skyrocketed, and the number of prescriptions for agitation plummeted. Yet another facility was built on the grounds of a K-8 school; the kids and elderly residents benefited in equal measure. All these stories vividly illustrate that elders need and want purpose, and that, even for people at the very end of life, such purpose – particularly the ability to help other living beings – can make a vast difference. “The battle of being mortal is the battle to maintain the integrity of one’s life,” writes Gawande.” We have at last entered an era in which an increasing number of [professionals and institutions] 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.”
I was particularly taken by Gawande’s description of his own father’s illness and ultimate death. His dad was a respected urologist in an Ohio college town. When we physicians experience our own parents’ decline and death, it is often the first time we recognize – in ways that cannot be conveniently compartmentalized by professional distance – the flaws of the system we work in, and how our own behavior may be complicit. Gawande’s critique of a neurosurgeon at his own hospital for failing to elicit his dad’s preferences and for offering some dreadful counsel; his insights into the challenge of balancing the roles of physician, counselor, and child; his description of the terrible time when his father fell and couldn’t get up and his mother slept on the floor beside him – and then couldn’t get up herself; his awful, role-shattering experience of having to catheterize his own father’s bladder – these are heartbreaking moments of blinding clarity. To his great credit, even as Gawande offers profound insights about these matters, he doesn’t shirk from their messiness and complexity.
I saw Gawande recently and congratulated him on the success of the book (it is currently fourth onThe New York Times nonfiction bestseller list), and the courage it took to write it. “I’m hoping this means that our society is finally ready to tackle these issues,” he told me. Maybe, or maybe people just love reading anything Gawande writes. But no matter – whether you come to this book because you are ready to better understand the realities of aging and what our society and the medical profession must do to improve things, or because you are a Gawande fan (I came for both reasons), you will not be disappointed.
Robert Wachter is a professor of Medicine at the University of California San Francisco.