Couple of recent business trips gave me some plane time to read this book. As the full title "Being Mortal - Medicine and What Matters in the End" clearly indicates, book material deals with how we should be treated when our time in this planet nears its end. Though depressing, certainly it is a book we all should read since the subject warrants a lot of social discussion and individual level understanding. Atul Gawande is a surgeon by profession who has made a name for himself in the last decade as a writer through his books such as The Checklist Manifesto, Complications, etc. Being a person of Indian descent, he starts off the book narrating at length how his grandfather (father's father) lived out his old age as a rich self-made landowner in India. There was a large extended family that supported him as age was catching up slowly disabling him. But since the family was well off and there were a large number of people available to take care of him, adjustments could be made to help him continue his life style. For example, going around all the agricultural land he owned each day was part of his routine. When he couldn't walk around the land briskly anymore, family got him a horse so that he can still go on his rounds. When his ability to even sit on the horse came into question, a servant followed him as he made his daily rounds and so on. Atul's father, who himself is a physician, had seen firsthand how his father lived out his last years. So, as a practicing physician in the US, he found how American society treated its own elderly totally objectionable. For a multitude of reasons, American families don't continue to function as large support network to ensure the quality of life for their family's elderly are retained come what may. It doesn’t feel practical in our current setup. Instead the elderly tend to live by themselves as long as they could. They don't feel comfortable living with their children as they feel that it is an unnecessary interference in their children's lives and a loss of independence for themselves. When they can't take care of themselves, assisted living and nursing homes start to show up in the picture. Most of these facilities are designed to make sure the elderly they care for are safe. Whether they enjoy their life is of secondary importance though given a choice most seniors will chose to prioritize their quality of life over safety.
Since families are not closely involved in the day-to-day operations of the elderly, what kind of end of life care each one wants does not get discussed at the right time. Sons & daughters confront those questions all of a sudden when the elderly are not able to make those decisions themselves oneday. This also leads to the convention of "doing everything we can" to save the life of the elderly. But this is done at the expense of their quality of life is not well understood, thus putting the elderly through a wringer making them suffer enormously though that is not what they would have wanted. This also has the downside of spiking the cost with no real return.
While these problems may appear intractable and hard to solve, author points out specific towns in US that have adopted the practice of doctors talking to patients during their routine visits (like annual physicals) about DNR (Do Not Resuscitate), Living Will, what kind of care they'd like to receive when they are terminally ill. This practice has transformed those localities. Since the discussion is pervasive, it is not making people uncomfortable. As the discussions have taken place around kitchen tables and doctor offices earlier, even if there is no written documentation, relatives and physicians have a very good sense of what the patients want when they are not able to make the decisions for themselves. This provides a lot of hope for turning the system around despite all the 'death panel' scare tactics politicians and irresponsible media use for temporary gains.
In the end it boils down to moving from "put a patient through hell temporarily for long term gains" approach used in medicine when patients are young, to "do all you can to help patient maintain quality of life and happiness" approach as they grow old. This transition has to be made routine even if it brings in some risks or can shorten their lives a little. Being comatose under a vegetative state for months may be technically prolonging one's life. But that is no way to "live".
Since the intended audience is general public, book is written like a series of stories with lot of detailed anecdotes (how the weather was, what she was eating, what clothes patient was wearing, how did he feel, etc.) that at times makes it feel like a lot of fluff. I couldn't help feeling that the content of the whole book could have been conveyed in a 15 page article. But I understand only when things are personalized this way in easy to read prose, the intended messages will get through, particularly when the audience is general public interested in light reading.
On a related note, I have been pushing all my friends to write out their Last Will and Living Will for the past 5+ years. It doesn't matter how young you are or how uncomfortable it may make you feel to think about your own mortality, you owe it to your family to document your wishes. I hear excuses such as “My family/setup is so simple, it doesn’t require a Will” or “I don’t have a lot of property and so why do I need to write a Will?”. But trust me, if you pass away unexpectedly without a Will, you will put your family through a lot of trouble. I have offered to provide my Will as a template where you can just change name and few personal details and sign it in half an hour to hold a legally valid Will of your own. Some friends took me up on the offer but not as many as I had hoped. Since it is a closely tied topic to this book, would like to make that offer again. If you'd like to get a copy of the template I used, just send me an email. Next ten days might be a good time to complete such tasks as things slow down during the holiday season.
Happy holidays and a wonderful new year to you and yours!
-sundar.
