Being Mortal

I just finished reading Being Mortal: Medicine and What Matters in the End, by Atul Gawande, MD.  I wish my father were alive to have read this book; he would have thoroughly appreciated the themes it covers.  As a small town private practice family physician, he lived them.

In Being Mortal, Dr. Gawande works through what happens at the end of our lives, and how we should best respond to it.  It's a question that is not discussed as much as it should be, and he makes several excellent points.

Death is a very different experience in the era of modern medicine than it used to be.  Society has gotten good at preventing many of the things (medical or social) that used to kill people when they were younger, which means we are much more likely to endure the decline which becomes inevitable as our bodies age.  But we as a society are not really ready to cope with that.  Medicine's desire to address discreet problems does not address the systemic issues that become the real issue for people as they age.

In a Norman Rockwell America, the elderly remain in the home with one of their children.  But in the end, that proves not to be a practical solution.  Because children have long since moved out of the parent's home, it's not remaining, but moving into their children's house.  And as the care needs escalate, those needs inevitably become more than a child/caregiver can provide.

Dr. Gawande discusses what assisted living started as, a place that can care for the infirm without institutionalizing them.  Much of the discussion in the book is around what is wrong in most nursing home care and end-of-life medicine - that there is no interest in individual desires, just efficient care-giving.

The solution, both in housing and in medicine, are in more a whole-person approach.  Real assisted living, palliative care, and hospice all work to use that approach.  The key factor is a willingness to discuss what is important to the person as they age and lose some of their capabilities.  The author cites a 2010 study by Mass General Hospital offered that palliative care in addition to treatment to ½ their patients with Stage 4 lung cancer.  “The result: those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice care earlier, experienced less suffering at the end of their lives—and they lived 25% longer.  In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.  If end-of-life discussions were an experimental drug, the FDA would approve it.”

We are reminded that medicine and institutions are designed to promote safety and longer life.  But the sick and the aged have priorities beyond merely being safe and living longer.  I am a staunch advocate of hospice, mostly because it provides care that is sensitive to those real priorities.

Dr. Gawande concludes by saying that:

"Our job in medicine is not to ensure health and survival, it is to enable well-being."

He's right, and hospice and palliative care are the services that currently address that.  We need a medical system where ALL care providers are focused on enabling well-being, and not simply addressing whatever immediate medical need there is.

Read the book.  Engage in discussions with those you love about their end-of-life desires. You will be happy you did.