End of Days

Facing the inescapable reality of death is not, generally speaking, good for the economy. The consumer frenzy of capitalism depends on our delaying our big moment of reckoning for as long as possible; once we start to view our property and possessions, our fashions and vehicles and even face-lifts, as temporary investments that won’t hold much value past the grave, a shift in priorities becomes necessary. And thanks to the modern tendency to extend adolescence well into middle age, many of us are only beginning to savor the more lavish spoils of the American dream when orthopedic shoes, blood-sugar monitors, and oxygen tanks rudely push their way into our picture.

This isn’t, it seems safe to say, the way it always was. The so-called Greatest Generation, in spite of various flaws, tended to face challenges, from World War II to botched cataract surgery, with stoical (if reductive) sewing-sampler grace. But the whippersnappers they’re leaving behind seem less likely to greet the inevitable with model composure. We Boomers and Gen Xers might be known for our rebellious natures and/or creative flair, but we’re not exactly famous for our courage under duress. When we do finally wake up and smell the Dilaudid drip hitting the IV and recognize that we won’t live forever, no matter what Irene Cara promised us in the chorus of “Fame”—well, let’s just say we will not go gentle into that good night. We will whine and kvetch and overanalyze and demand constant tweaks to our pharmaceuticals. We will also seek out brand-new delusions that might protect us from the unbearable injustice of it all. In this Jetsons-like age of wristwatch and eyeglass computers, we will ask, “Why hasn’t someone turned rapid decline and death into something soft and serene and Disneyfied? Can we please have less of the chills and spills of Mr. Toad’s Wild Ride and more of the gratitude and morphine-addled smooth sailing of It’s a Small World?”

The glory and the horror of Atul Gawande’s latest offering, Being Mortal: Medicine and What Matters in the End (Metropolitan Books, $26), which remains near the top of the best-seller lists almost a year after its publication, lies in the author’s unrelenting delight in deflating our dogmatic will to control (or at least significantly mitigate) the terrors of old age and death. Even with an abundance of careful planning and reflection, the aged still find themselves on a perilous, unpredictable, and often very lonely path. Whether we live alone, pay dearly for assisted living, or land unceremoniously in a nursing home, whether we are afflicted with countless maladies or run marathons until we’re seventy-five, the last days of our lives tend to be unpleasant in a range of ways that most of us never anticipate. In this modern age of perpetual treatment and safety-first living, with so few extended-family members nearby, almost none of us has the luxury of living independently all the way up until we drop dead at a ripe old age. Even those graced with giant bags of money and an army of loving friends and relatives will one day find themselves staring at institutional tile ceilings, hooked up to monitors, and clutching an indifferent nurse’s hand as they shuffle off this mortal coil alone.

Our instinctive revulsion at such images as unnecessarily pessimistic is testimony to our stubborn resistance to the realities in play for those dying in the developed world today. But while Being Mortal is largely devoted to the painstaking documentation of such realities, it is, like Gawande’s other books, Complications, Better, and The Checklist Manifesto, more than just a carnival of morbid truths. Through vivid storytelling and thoughtful observation, Gawande explores the gaps between the compromised, isolated lives we’ve resigned ourselves to in old age and a few more-hopeful alternatives. As Gawande suggests, some small shifts in perception, and in the way we approach gerontological treatment, could lead to vast improvements in the lives of millions of aging and dying people.

Doctors, Gawande asserts, must train their focus away from the endless conveyor belt of treatment and cure and on to more-immediate threats to an individual’s quality of life. When, for example, an eighty-five-year-old woman comes into the office with a possible spot of metastasized cancer on her lungs, her geriatrician is right to be less worried about the cancer than about the woman’s increasingly perilous balance. “Each year, 350,000 Americans fall and break a hip,” Gawande explains. “Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again.” Instead of monitoring the spot on her lungs, the doctor sends her to a podiatrist to address her balance problems. For younger people focused on optimizing every dimension of their lives, the notion of letting a cancer grow while talking about clipping your toenails more often might sound perverse. But the kind of measures that outside observers might dismiss as overly fatalistic or compromised may actually be what most directly benefit an elderly patient.

Our understanding of older people’s priorities requires some adjustments as well. “How we seek to spend our time,” Gawande writes, “may depend on how much time we perceive ourselves to have.” As Laura Carstensen, a scholar of the aging process, has discovered, not only do we increasingly concentrate on the present moment as we age, but also, more surprisingly, we tend to revel in it. “Far from growing unhappier, people reported more positive emotions as they aged,” Gawande notes in his summary of Carstensen’s findings. “They became less prone to anxiety, depression, and anger.” The failure to recognize this crucial shift in perspective amounts to a misdiagnosis; it disregards a patient’s more realistic and pragmatic view of things in favor of the medical profession’s own narrow focus on treatment, permanent fixes, and a strictly theoretical distant future. It shouldn’t be such a feat to “age without having to choose between neglect and institutionalization,” Gawande writes. Yet, often, “our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.”

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Ever the cross-disciplinary Renaissance man, Gawande demonstrates the same flair for dramatic narrative in Being Mortal that can be found in his previous books. While recounting the tale of senior advocate Bill Thomas, Gawande marvels at the strange twists in the man’s path: from a charismatic but underachieving high school kid destined for a job pumping gas to a Harvard-educated doctor to a farmer with a nursing-home day job who discovered within himself a driving need to improve and revolutionize the way nursing homes are organized and run. Instead of breezing through Thomas’s reforms, Gawande zooms in on a meeting at which Thomas proposes that his bosses at the nursing home apply for a New York State grant for innovations in order to do battle with what he calls “the Three Plagues of nursing home existence: boredom, loneliness, and helplessness.” Thomas argues that they should introduce more green plants—as well as two dogs, four cats, and some birds. He maintains that a steady chorus of birdsong will greatly improve the mood of the place. “How many birds are you talking to create this birdsong?” his boss asks. “Let’s put one hundred,” Thomas answers. His boss is unconvinced, but he humors Thomas, assuming that the state will never fund such a wild initiative.

Then Thomas visits the capitol to lobby for his project personally, and he wins the grant plus all the regulatory waivers necessary to fulfill his vision. “When we got the word,” the boss recalls, “I said ‘Oh my God. We’re going to have to do this.’” The results of Thomas’s experiment, though, are just as dramatic. After the administrators allow the residents to care for some caged birds, the entire dynamic at the home changes. Residents who the staff thought were mute actually begin to talk. Residents who were “withdrawn and nonambulatory started coming to the nurses’ station and saying ‘I’ll take the dog for a walk.’” Total drug costs fell to 38 percent of those at a similar facility; deaths fell 15 percent. But, Gawande asserts, “the most important finding of Thomas’s experiment wasn’t that having a reason to live could reduce death rates for the disabled elderly. The most important finding was that it is possible to provide them with reasons to live, period.”

Today’s nonfiction-publishing market is glutted with poorly written tracts on the statistics-fixated sociological trend of the moment. By contrast, the somewhat surprising popularity of Being Mortal is a welcome throwback to a not-so-distant time in America’s reading culture when serious, carefully argued work could claim a significant following. Gawande’s thoughtful survey of the end stages of life is at once wide-ranging and precise, dynamic and well reasoned, impassioned and pragmatic, with all of its big-picture ruminations folded into page after page of graceful, exacting prose. More than just a great writer dedicated to reexamining medicine’s long-held assumptions, Gawande is a passionate advocate for the patients themselves. From his intimately rendered anecdotes of patients he has treated to the heart-wrenching story of his own father’s unexpected illness and death, Gawande demonstrates that the path to the grave is littered with good intentions and disastrous, downright horrifying outcomes. Being Mortal should be mandatory reading for those of us who want to take the big sleep armed with more than just our own fears and drug allergies. Death may be inescapable, but, as Gawande argues so convincingly, getting older shouldn’t have to feel like running for your life.

Heather Havrilesky is the author of the memoir Disaster Preparedness (Riverhead, 2010).