“Being Mortal: Medicine and What Matters in the End,” Atul Gawande’s masterful exploration of aging, death, and the medical profession’s mishandling of both, is his best and most personal book yet — though a little depressing, until you get to the parakeets.
In the first half, Gawande details, through intimate stories of his patients’ and his own relatives’ experiences, the realities of old age in modern America: broken hips and dementia, overwhelmed families and bank account-draining geriatric care, loneliness and loss of independence. Then, Gawande introduces Bill Thomas, who, as a young doctor in the early ’90s, proposed a radical idea: Treat old people like people.
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Thomas redesigned the upstate New York nursing home where he served as medical director, planting a garden for residents to tend and an on-site day care so they could interact with children. He also ordered 100 parakeets to fill the place with song, but the cages arrived unassembled. The staff scrambled to put them together as birds flew free, and the old folks, as Thomas recalled, “laughed their butts off.” Death rates and use of sedatives in the nursing home plummeted.
There’s not much laughter, birdsong, or good news in the rest of “Being Mortal,” but this book is no lament. Gawande, a surgeon at Brigham and Women’s Hospital, a public-health innovator, and a staff writer for The New Yorker, is as interested in solving problems as in enumerating them. In his previous books, including “Complications’’ and “The Checklist Manifesto,’’ Gawande focused on difficult issues doctors face, such as how to ensure competence and avoid medical errors. In “Being Mortal,” he takes on a question that everyone faces: How can we make our last days more comfortable, meaningful, and affordable?
Gawande begins by contrasting the final years of his wife’s grandmother in America with those of his own grandfather in India. These two stories illustrate the central paradox that runs throughout “Being Mortal”: Sophisticated medical care does not guarantee and often actually prevents a good end of life. His wife’s grandmother, living in a country where old age is treated as a medical problem and independence is often overvalued, spent a lot of time in hospitals or home alone. Gawande’s grandfather lived on his beloved farm, surrounded by family until his death.
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The medicalization of mortality becomes most apparent at the very end of life, when the American health system spends billions of dollars on what Gawande calls “the medical equivalent of lottery tickets,” aggressive and often futile interventions that make patients miserable and keep them apart from loved ones. In “Letting Go,” one of two chapters in “Being Mortal” based on New Yorker articles, Gawande is unsparing in his criticism of doctors, himself included, whose own inability to confront the fact of death prevents them from counseling patients wisely. (“Letting Go,” while excellent, centers on the story of a 34-year-old woman who learned she had terminal cancer while pregnant and feels a bit out of place in book otherwise about old age.)
Gawande offers no manifesto, no checklist, for a better end of life. Rather, he profiles professionals who have challenged the status quo, including Bill Thomas and other geriatricians, palliative-care specialists, and hospice workers. Particularly inspiring are the stories of patients who made hard decisions about balancing their desire to live longer with their desire to live better. These include Gawande’s daughter’s piano teacher, who gave lessons until the last month of her life, and Gawande’s father, also a surgeon, who continued work on a school he founded in India while dying of a spinal tumor.
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In one of the most moving passages in the book, Gawande’s father, in hospice, rises from his wheelchair to hear his son lecture at their hometown university. “I was almost overcome just witnessing it,” Gawande writes.
He’s awed not only by his father’s strength, but by the hospice care that helped the dying man articulate what mattered most to him, and to do it. Gawande thinks, as he watches his proud father climb the bleachers, “Here is what a different kind of care — a different kind of medicine — makes possible.”
Suzanne Koven is a primary care internist at Massachusetts General Hospital and writes the “In Practice” column for The Boston Globe. She can be reached at www.suzanne kovenmd.com.