Being Gawande

Atul Gawande“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 – ComplicationsBetter, 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.

11 replies »

  1. As a Hospice Chaplain my patients have soteriological and eschatological concerns that need to be addressed during the journey of dying. The medical model of prioritization for death does not always align with the spiritual or religious paradigm and it creates some distress in staff, patients and their families and friends. In our contemporary society, with advanced techniques for prolonging existence (but not necessarily life as most would define it), we need to be more sensitive to what matters most to the dying. I appreciate Dr. Gawande’s work and enjoyed the recent FRONTLINE documentary about him.

  2. Interesting article. I have not read this book, but reading the preview of Gawande’s description of his father’s illness and death really hit home to me. I am not a physician, but I am a nurse, and I can relate with watching my own family member’s declining health status. This puts me in a vulnerable state, at the hands of the doctors and nurses. I am no longer the health care professional, but rather, the concerned family member. Like Gawande, this is the time I see flaws in the system and watch health care from a window. Having a sick loved one really puts health care into perspective for health care workers. It helps me strive to be the best nurse I can be. I want my patients and their families to know this is how I would want care for my family member.

  3. Death is a profitable business. Just ask the hospice corporations and the funeral homes. Everyone is on the take…hospital administrators are the worst. He does not address that.

  4. Life is 100% fatal, in spite of what Dr. Palmer (above) might want you to think. Seeing Bob Wachter review a new Atul Gawande book about the mortality each of us carries with us from birth? Well, it puts the book on the top of my Kindle list.

    Having walked the end of life journey with my parents, a spouse (cancer), and a close friend (again, cancer), I know that making your wants/wishes clear to anyone who might speak for you when you can’t speak for yourself is CRITICAL. I have a 3″ square QR code tattooed on my sternum that links to my advance directive. Just in case.

    Not kidding. Starts some meaningful, meaty conversations in the rooms where I do my work.

  5. I enjoyed Gawande’s book and thought it was very well done.
    The points that came through most clearly to me are (1) it’s important, especially for the elderly, to make clear ahead of time what care they want and don’t want in an end of life situation, (2) adult children who can’t let go are much more willing to spend someone else’s money on futile or marginally useful care than their own, and (3) the healthcare system can do a much better job in trying to draw terminally ill patients out regarding their goals, hopes and fears for the time they have left and to tailor treatment to address those concerns as much as possible. The increasing availability of palliative care teams and hospices nurses can help to facilitate this approach.

  6. I read Gawande’s first two books and, while they were fun to read, I noticed that when he wrote about things in my areas of expertise (and that aren’t his) he’d include a few oddball statements that didn’t make any sense. It made me wonder about the other stuff I couldn’t assess . . . should I trust him?

    For instance, he has a bizarre and inaccurate definition of “six sigma,” and in Better suggests that there isn’t enough money to compensate all victims of adverse events fairly. (That is the same thing as saying “costs > benefits” which means doctors shouldn’t be operating period!)

  7. you sold me, Bob – but then I’m a Wachter fan as well as a Gawande fan

  8. Too many molecular clues about aging are piling up. Read about telomeres and P53, et al. Don’t fret. Death will be voluntary. Not the time to be lugubrious.

  9. Interesting. I’ve not yet gotten around to this book. Here’s some stuff written long ago:

    [Homage to Sir Thomas Browne]

    Shall I tell you once more how it happens?

    Even though you know, don’t you? You were born with the horror stamped upon you, like a fingerprint. All these years you have lived you have known. I but remind your memory, confirm the fear that has always been prime. Yet the facts have a force of their insolent own.

    Wine is best made in a cellar, on a stone floor. Crush grapes in a barrel such that each grape is burst. When the barrel is three-quarters full, cover it with a fine-mesh cloth, and wait. In three days, an ear placed low over the mash will detect a faint crackling, which murmur, in two more days, rises to a continuous giggle. Only the rendering of fat or a forest fire far away makes such a sound. It is the song of fermentation! Remove the cloth and examine closely. The eye is startled by a bubble on the surface. Was it there and had it gone unnoticed? Or is it newly come?

    But soon enough more beads gather in little colonies, winking and lining up at the brim. Stagnant fluid forms. It begins to turn. Slow currents carry bits of stem and grape meat on voyages of an inch or so. The pace quickens. The level rises. On the sixth day, the barrel is almost full. The teem must be poked down with a stick. The air of the cellar is dizzy with fruit flies and droplets of smell. On the seventh day, the fluid is racked into the second barrel for aging. It is wine.

    Thus is the fruit of the earth taken, its flesh torn. Thus is it given over to standing, toward rot. It is the principle of corruption, the death of what is, the birth of what is to be. You are wine…

    Dead, the body is somehow more solid, more massive. The shrink of dying is past. It is as though only moments before a wind had kept it aloft, and now, settled, it is only what it is— a mass, declaring itself, an ugly emphasis. Almost at once the skin changes color, from pink-highlighted yellow to gray-tinted blue. The eyes are open and lackluster; something, a bright dust, had been blown away, leaving the globes smoky . And there is an absolute limpness. Hours later, the neck and limbs are drawn up into a semiflexion, in the attitude of one who has just received a blow to the solar plexus.

    One has…

    Examine once more the eyes. How dull the cornea, this globe bereft of tension. Notice how the eyeball pits at the pressure of my fingernail. Whereas the front of your body is now drained of color, the back, upon which you rest, is found to be deeply violet. Even here, even now, gravity works upon the blood. In twenty-four hours, your untended body resumes its flaccidity, resigned to this everlasting posture.

    You stay thus.

    You do not die all at once. Some tissues live on for minutes, even hours, giving still their little cellular shrieks, molecular echoes of the agony of the whole corpus. Here and there a spray of nerves dances on. True, the heart stops; the blood no longer courses; the electricity of the brain sputters , then shuts down. Death is now pronounceable. But there are outposts where clusters of cells yet shine, besieged, little lights blinking in the advancing darkness. Doomed soldiers, they battle on. Until Death has secured the premises all to itself.

    The silence, the darkness , is not for long. That which was for a moment dead leaps most sumptuously to life. There is a busyness gathering. It grows fierce.

    There is to be a feast . The rich table has been set. The board groans. The guests have already arrived, numberless bacteria that had, in life, dwelt in saprophytic harmony with their host. Their turn now! Charged, they press against the membrane barriers, break through the new softness, sweep across plains of tissue, devouring, belching gas— a gas that puffs eyelids, cheeks, abdomen into bladders of murderous vapor. The slimmest man takes on the bloat of corpulence. Your swollen belly bursts with a ripping sound, followed by a long mean hiss.

    And they are at large! Blisters appear upon the skin, enlarge, coalesce, blast, leaving brownish puddles in the declivities. You are becoming gravy. Arriving for the banquet late, of course, and all the more ravenous for it, are the twin sisters Calliphora and raucous Lucilia, the omnipresent greenbottle flies, their costumes metallic sequins. Their thousands of eggs are laid upon the meat, and soon the mass is wavy with the humped creamy backs of maggots nosing, crowding, hungrily absorbed. Gray sprays of fungus sprout in the resulting marinade, and there lacks only a mushroom growing from the nose.

    At last— at last the bones appear, clean and white and dry. Reek and mangle abate; diminuendo the buzz and crawl. All, all is eaten. All is done. Hard endlessness is here even as the revelers abandon the skeleton.

    You are alone, yet again.

    Selzer, Richard (1996-04-15). Mortal Lessons: Notes on the Art of Surgery (Harvest Book) (Kindle Locations 1368-1483). Houghton Mifflin Harcourt. Kindle Edition.

    Now, THERE’S a writer.