Being Mortal: Medicine and What Matters in the End by Atul Gawande
Mr. Gawande is an excellent writer. He’s the kind of writer who writes stories, and then weaves them into the point he’s trying to make. (Morgan Housel does that, too). This helps make Being Mortal a fast read, but it has spots worth slowing down for. In short, this is a thoughtful book and I think most people would benefit from reading it and then discussing it with loved ones.
Being Mortal is concerned with what happens to us at the end of our lives: specially, what happens to us in the medical system. Modern medicine allows us to keep people with serious illnesses alive far longer than at any other time in human history. Unfortunately, this can lead to hard decisions and high costs, and it’s not clear that our medical interventions make people’s final years better.
I witnessed this with an older relative. She fell at home, and later the doctor found a large deep tissue injury that was infected and required surgery. With the hope it would heal, she had another surgery, experiencing delirium in the hospital. She then had a stay in a nursing facility, where she received (at times) substandard care and had a wound management system applied incorrectly, ultimately leading to another infection that required re-hospitalization, another surgery and more delirium. By this point my husband’s parents had enough and took her home, but the surgeon still held out hope she would heal, even as she wasn’t eating. She had an expensive and resource-intensive wound vac in place for weeks before transitioning to hospice.
While the book doesn’t offer any easy answers, it does suggest some questions that should be considered when someone has a serious illness.
- What do they understand about their illness and their prognosis?
- What are their concerns about what lies ahead?
- What kind of trade-offs are they willing to make? What trade-offs are they not willing to make?
- How do they want to spend their time if their health worsens and time is short? What are their goals?
- Who do they want to make decisions if they can’t?
One of the physicians in the book phrases it another way: “How much are you willing to go through to have a shot at being alive and what level of being alive is tolerable to you?”
Honestly, these are not bad questions to ask before someone becomes seriously ill. They are not bad questions to ask yourself and discuss answers with trusted loved ones. Catastrophic things can and do happen to healthy, active people at unexpected times and with little warning – I see it regularly in the hospital. Having a healthcare provider assist in this discussion would probably be helpful (especially to make sure #1 is accurate), but I don’t think it’s essential. If you have a firm grasp on the answers to these questions, even if you don’t have the answers to nitty gritty medical questions, your healthcare team should be able to help apply them if you make goals/hopes/wishes clear.
One thing that felt prescient was Mr. Gawande’s discussion of medically-assisted suicide. He doesn’t outright condemn the practice, but worries that it essentially provides a way for people to ignore caring for the dying – you don’t need to, because if things are too bothersome they can just end things immediately. He notes that “the fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success [but] failure,” and links it to inadequate hospice programs. If people have access to resources that will help reduce suffering and improve their lives in their final days, he argues, they won’t choose to cut them short.
Unfortunately, this is what is happening in Canada. Canada legalized medically-assisted suicide, or “MAID” (medical assistance in dying) in 2016, two years after Being Mortal was published. It is also known to have inadequate social supports and hospice resources. Today, one in twenty Canadians dies from medically-assisted suicide. Despite this evidence of failure, people instead seem to be interpreting it as evidence of its success. Proponents are moving forward with the goal of expanding MAID eligibility to people who have chronic mental illness. Cynically, I wonder if more people choosing to die saves the healthcare system dollars.
One thing this book lacks is a Christian perspective. Mr. Gawande is areligious. While I still think this book provides a lot of wisdom and things to think about, faith plays a role in our final days that we must acknowledge and can also make a big difference in our perspective of things.
SDG