Tuesday, September 6, 2016

Being Mortal: A Review and Thoughts

I think I added this book to my library holds queue after I finished When Breathe Becomes Air because I was all like "I need more books about dying written by doctors!" Okay, so Atul Gawande is not actually facing/reflecting on his own imminent death, nor is this a poetic tribute to what it means to be alive. This one is much more straight fact nonfiction.

But it's still very well written, incredibly interesting, and a very important read. To give a brief summary, Gawande realizes at some point in his career that he, as a doctor, and the modern medical profession as a whole, really don't know how to face death. To modern medicine, death is a failure, death is to be avoided at all cost, whatever cost. There is always another treatment, always another surgery, always another experimental drug, and never a way to tell patients they are going to die. And yet, we all die, we are all still mortal. So Gawande sets out to explore what death means in this modern medical environment, and how best to go about the medicalized process of dying. The first part of this book focuses on aging and the medical practice of geriatrics, while the second half focuses on the medical journeys of people with terminal illnesses.

So, this is a super depressing book. It's not fun to think about death, or even just growing older. In fact, my husband kept asking me why I was reading this book because I would complain to him every night about all the discouraging and depressing things I was reading, and my answer was, "It feels important. It feels like something we should all be thinking about a little bit more."

It also felt a little too close to home, as throughout the time I was reading this book, my own grandmother was in and out of the hospital with various infections. My grandpa sends regular family email updates on their condition, and the day I finished this book, I read an email from him detailing his recently failed stress test and how he probably needed to schedule another angiogram (he had a heart attack last fall), but that he didn't know when he could fit that in. Oh, and he had just pulled an all nighter at the ER dealing with my grandmother's latest infection. They are desperately working to remain independent in their home, but my grandpa (who will be turning 90 next spring) is so overwhelmed by my grandmother's needs he is not taking care of himself. At a distance of several thousand miles, I'm not exactly in a position to help much, except to force this book into the hands of all my aunts and uncles who are scurrying around trying to provide what support and help they can.

It's a difficult process, this business of growing old. Frankly, it doesn't sound like much fun at all. Gawande's descriptions of the modern nursing home system are down-right horrific (granted, better than historical options, but still a really, really depressing place to end up). Basically what our modern American system has done is turn geriatrics into patients who need to be treated for symptoms, rather than people who still deserve rich and full lives while they face the unavoidable breakdown processes of death.

The key question that Gawande keeps coming back to is "What makes life worth living?" Many elderly people who find themselves reliant on other people or locked away in nursing homes fall into deep depressions because they are unable to hold on to the things that made their lives meaningful: their autonomy and independence, their home and sense of belonging, and their ability to make choices for themselves. He told story after story after story of older people who lost control of their lives because of their medical problems, and were unable to make the most basic decisions for themselves, like when to go to bed, when to wake up, and what to eat. This is an extremely undignified way to live, and it's no wonder so many of our elderly withdraw, face crippling depression, or continue to live in unsafe conditions simply out of fear of losing control. (Funnily enough, hearing these stories about the elderly actually made me have more compassion for my own children, who I realize are in the exact same position: they just want to control their own lives and not be told so much what to eat, when to eat, when to sleep, etc. Obviously, toddlers need a bit more guidance than elderly people, but our modern medical system seems to treat geriatrics exactly the same way as I treat my defiant toddler: with very little respect for their own wishes).

But this question, "What makes life worth living?" applies equally well to those facing cancer and other terminal illnesses, but the answer with these patients seems to be even more ignored in favor of that one more treatment, that more surgery, that one more experimental drug will be that magic pill that offers decades more of life. But in many, many, many cases, these treatments are actually worse for the patient than the illness itself, and people end up living the last months of their lives in debilitating misery, hooked up to life support or unable to function in any meaningful way.

I personally became more terrified of being treated for cancer than dying of cancer when I read The Emperor of All Maladies. I don't have cancer right now, and live in that blissful state of ignorance and delusion, where I can believe that will never happen to me! However, after reading about what these medical treatments can do to a body, I firmly believe that sometimes the cure is worse than the illness. Thanks to my pregnancies, I know that I don't handle pain, invalidism, and discomfort for extended periods of time with any sort of grace, and if I'm ever faced with trials like a severe terminal illness, I really would like the focus of my treatment to center around improving my quality of life for as long as possible rather than trading my quality of life for length of time. After reading When Breath Becomes Air, I became even more convinced of the value of palliative care over aggressive fighting to the bitter end.

But this is a personal and honestly, rather selfish choice. It becomes much more complicated when I take my husband and children into consideration, because how do you not fight for extending time with them? And what if it were my own child or loved one facing such a terminal illness? Would it not be me shouting over and over "DO NOT GO GENTLE INTO THAT GOOD NIGHT!?"

It is because of these hard emotional complications to the questions surrounding suffering and death that Gawande's book becomes so important. He advocates for these conversations to be happening, earlier rather than later. He believes people need to consider what it is they really want from life, and then work with their doctors and the medical profession to make those priorities happen. Is it just more time, no matter the cost? Or are there other priorities, like being able to stay in your own home, eat real food for as long as possible, visit with friends and families, travel or engage in other hobbies for as long as possible? The important question to consider is at what point life would no longer be worth living. I know my own answer will entirely depend on circumstances, but when the time comes, whether earlier or later, what I think I want most is control, the ability to be in my own home hopefully surrounded by the people I love, enjoying the things that make my life meaningful for as long as possible while making peace with my end.

Sorry, I know this is an incredibly depressing topic, but I still highly recommend this book. It's super important stuff to be thinking about, whether for yourself or for the loved ones around you who will have to face these decisions someday.

Have you read it? Thoughts?


  1. Oh, this one is on my to-read list! I'm sure I will have more to say once I read it! I want husband to read it too, since he is a Family Practice doc and deals with this a lot more often than I do.

    1. I can't recommend this enough! I'd be especially interested to hear your husband's take on it.