Thinking Immortal but Being Mortal

Being Mortal by Atul Gawande is an important book for those who have thought about the death of themselves or a loved one; it is an essential book for those who never considered the question.

Although not specifically delineated that way the book can be thought of as divided into three parts.

Part 1: “Life is a non-winning proposition.” Russell Berg

The first part deals with how we die. I tell patients that we peak between 20 and 25 and then it is a down hill course to oblivion*. Gawande discusses how this takes place and uses the aging of teeth as an example.  Even this most inert part of our body is not immune to the ravages of time. He discusses various theories as to why this happens but favors the notion that we are complex self-correcting machines where eventually the mistakes over take the corrections and we end with overall system failure.

For all of previous human history that end was usually fairly sudden and usually the result of an infection.  Pneumonia was referred to as the old person’s friend. The downhill course to oblivion ends at a cliff.

Now, for the most part, the downhill ride is punctuated by a series of events that permanently reduce our capacities but, because of modern medicine, it becomes a drawn out affair. We aren’t dead but we must learn to live with what we have lost.

Part 2: Don’t live free and don’t die

Gawande goes on to discuss how society has had to come to grips with this extended twilight world that the moderately to severely debilitated aged live in.  He traces the history of the development of the nursing home industry as a well-meaning solution for dealing with people who are unable to care for themselves. He notes that the quality of care is orders of magnitude better than the poor houses they replaced but their principle problem is that there, patients lose their autonomy.  He notes that like the military and prisons nursing homes are the institution in which the individual’s schedule – when you get up, when you eat, when you wash, when you socialize - is completely directed by someone else. This loss of autonomy results in a loss of a sense of self.

There are movements afoot that Gawande talks about to give more autonomy to the client.  The assisted living arrangement was started to give individuals the opportunity to decide when they want to get up, eat, socialize, etc. However, many of the questions revolving around autonomy raise questions about safety.  Can an individual live alone, go out by themselves, without a walker or cane, drive? The important point he addresses here is the interpersonal nature of this problem. This is often a point of conflict between the elderly individual and their loved ones.  While these sorts of issues must be dealt with on a case-by-case basis, being able to frame the problem in this way makes it easier for both sides to come up with solutions to their differences.

Part 3: What are your hopes and what are your fears

In the last part of Being Mortal the author talks about what happens when that decades-long downhill course turns into a rapid rush punctuated by modern medicines valiant but ultimately futile attempts to prevent the inevitable. He deals with this issue objectively quoting authorities and citing statistics; professionally how he dealt, both well and badly, with the problem with patients: and personally in dealing with the prolonged illness and death of his father. 

He feels the medical profession is understandably overly directed toward cure and the patient, equally understandably, is overly optimistic for a cure.  The result can be a futile pursuit of doing too much for too long to the detriment of the patient.

He favors taking a step back, realistically assessing a prognosis, and then trying to optimize everyday that the individual has left to them.  Once an estimate of a prognosis has been determined the first and foremost question, which is straight out of hospice care, is:

What are your hopes and what are your fears; what are you willing to do to realize your hopes and avoid your fears? *

The object is to think as clearly as possible about how to optimize the measurably finite time you have left and make each day a blessing. Gawande’s personal and professional recollections give tangible examples as to how this can work out in practice to the benefit of the patient, their family, and even the provider. 

Being Mortal gives the reader an opportunity to think through these issues before they come to the fore so that the individual can be better prepared when the inevitable comes.

It has not only been beneficial for patients but has been widely read in the medical community resulting, at least in the circles I run in, with a more ready embrace of palliative and hospice care.

*I go on to tell patients that there are 3 things and only 3 things you can do to keep the slope as flat as possible.

1.     Don’t put bad things into your body. (Heroin, nicotine, high fructose corn syrup, etc.)

2.     Put good things into your body. (Fruits and vegetables)

3.     Exercise.

** “What are your hopes and what are your fears; what are you willing to do to realize your hopes and avoid your fears? The object is to think as clearly as possible about how to optimize the measurably finite time you have left and make each day a blessing.”

This should probably be the guiding principle of our entire finite life. But for most of us it isn’t and that is probably because while our life is, of course, finite it is not measurably so in any meaningful way for us. We are all going to live forever until we’re not.