Atul Gawande tackles the hardest challenge of his profession: how medicine can not only improve life but also the process of its ending.

Essential Book Information

Gawande, a practicing surgeon, addresses his profession’s ultimate limitation, arguing that quality of life is the desired goal for patients and families. Gawande offers examples of freer, more socially fulfilling models for assisting the infirm and dependent elderly, and he explores the varieties of hospice care to demonstrate that a person’s last weeks or months may be rich and dignified.

Basic Plot Summary 

Being Mortal looks at trends in the impact of using all available means to keep people alive, and how that affects someone’s final days. When is the right time to stop treatment? How much is too much? When is the right time to die? It used to be that, when it was time, one’s final days were spent at home, with family.

These days, they are likely to be spent in an institution of some sort, and as likely as not, entail the patient being hooked up to sundry tubes and wires and flashing, beeping devices. It is important to identify exactly what it is that a person wants, or fears most, as a basis for decision-making. If your needs are minimal it speaks to one set of decisions. If your needs are more substantial, it speaks to another.

One person said that as long as he could watch football and eat chocolate ice cream, life would be worth living. Others have a more extensive list of must-haves in order to make life worth living. It does lead one to consider what your list might include. What if you couldn’t clean yourself? What if you could only have food through tubes? How much pain could you live with, and what measures would be acceptable to ameliorate it? What would keeping me alive cost? And, how much is too much?

All these questions figure into deciding the appropriate level of care. One fascinating section here had to do with hospice care, which need not take place in a hospice building. That was news to me. And, it is a revelation how such care impacts patients.

Review 

A clear, uplifting, and eloquent education on the deficiencies of the medical establishment in end-of-life care and promising progress toward improvements. This Boston surgeon has already authored accessible books on the human art behind the science of medicine with his “Complications” and “Better”. He is a master at using stories of his cases to address disparities between our expectations and the reality of medical practice and drawing on diverse research to advocate for needed changes. Here he delves into the tragedy of so many people at the end of their life dying in the depersonalized, institutional conditions of hospitals and nursing homes.

In his own training he was taught to see death as the enemy to fight at every step with everything in the arsenal of medicine and didn’t conceive any role for doctors in facilitating the dying process. He does remember a seminar in which they read Tolstoy’s “The Death of Ivan Ilyich”, which highlighted the benefits the character gained from simple, humane interactions with his servant. But, that lesson was soon forgotten.

Only when some of his surgical interventions came to a bad end with complications and a miserable death in the ICU did he come to consider changing how he approached his cases. For one man, with cancer invading the spinal cord, he successfully removed enough to delay the onset of paralysis, but he never recovered from the procedure. Such failures led the good doctor to rethink his ingrained approaches.

In a set of brief chapters, Gawande adroitly covers innovations in making nursing homes more humane, the advent of assisted living solutions, and growth in palliative care and hospice services. Simple approaches like allowing nursing home residents to have pets or opportunities to socialize with kids in a nearby after-school programme had surprisingly powerful benefits.

The power of assisted living programmes to preserve privacy and autonomy while fostering socialisation and sense of community is illustrated with exemplary stories. Just family communication about end of life care decisions by palliative care providers had a huge impact on reducing costly ER and ICU utilisation.

The lesson the Gawande learned and began applying to his patients (and the situation of his own father) was to take the time to find out what gives the person a sense of meaning and purpose in life and to explore the trade-offs they are willing to make to best fulfil those goals relative to the risks of procedures aimed at giving them a longer life. But, the challenge remains in every case to guide his patients on when to stop the pursuit of treatment in favour of concentrating on living the best they can with what they have left.

Simply put: this is a book about dying. But, on one’s own terms. Gawande boldly argues that the medical world has got it wrong when it comes to the treatment of the dying. The objective of medicine should not be to ensure health and survival; rather it should be about the quality of life and what it means to die with dignity, a sense of purpose, and most importantly, control over one’s life. It’s about being able to write the final chapter the way you want to and to enable well-being in the sense one wishes to be alive. It’s considering hospice versus emergency room care. What an unpleasant topic, but WHOA, what a relevant one!

Through a series of interviews with seniors and the terminally ill, he asks them what means the most to them; what are they willing to sacrifice and what they won’t, in order to extend their life a little longer. He examines how the dying were treated historically to the cultural, traditional institutionalised view we have now. Written humanely by a surgeon who in my opinion, has got it so right. I can only hope to have a surgeon as intuitive and caring as he, as I shape my ending chapter. 

Recommendation

This is very well read, amazingly relevant, and accessible. It’s filled with real world examples as well as a few statistics. It is a must-read for everyone young or old because we don’t think about our end days properly or even ask the right questions. Worse, we don’t understand what others are thinking or what their goals are. I’ll only say that I think time in reading this is important, given the weighty topic. 

Rating

5/5

Being Mortal offers not just a fascinating look at the history of late life care and living options, it not only offers a review of what is happening out there in the field of facilities for the frail and in the theories of how to approach late life care, it not only offers sage advice on planning for eventualities that we must all face sooner or later, it does all these things with humour and clarity, the bookish equivalent of an excellent bed-side manner.

It is a fast read, too, useful if time is short. I would strongly suggest adding Gawande’s book to your bucket list, before -you know- it gets kicked. This is must-read stuff.

Review compiled by Habab A. Iraqi, 2021