A Discussion of Being Mortal: Medicine and What Matters in the End

      In my spare time, I enjoy reading books that relate to the field of psychology. I imagined it could be fun, and potentially helpful, to present some of the material I have read, as well as impressions I gained. My latest read has been “Being Mortal: Medicine and What Matters in the End” by Dr. Atul Gawande (2014a, 2014b).

      In his book, Dr. Gawande discusses aging, dying, and medicine. He proposes that the field of medicine is often used in a way that reduces quality of life and its length. He discusses how we might balance use of medical interventions with consideration of personal values, including what an individual considers a life well-lived. He discusses the history of nursing homes, including that they were modeled after hospitals, where safety and physical wellness were placed in high value. He notes that living in a hospital setting, with personal choice and privacy reduced, can negatively impact one’s well-being. He adds that, particularly in modern society, many older adults do not want to live with family and experience reduced personal choice. He proposes balance between independence and medical supports. Concerning end-of-life circumstances, he proposes the benefits of hospice care in lengthening life and increasing its quality (Gawande, 2014a).

      Multiple medical events are likely to occur with age. Prior to the advancement of the medical field, people died at earlier ages. The previous life expectancy in 1900 was in the 40th decade. Now, individuals may live to be in their 80s or beyond. Dr. Gawande notes that doctors treating older adults with multiple medical events may get in a pattern of whack-a-mole, trying to knock out one problem at a time, without necessarily acknowledging the elephant in the room, which is individuals’ eventual decline and death (Gawande, 2014a).

      Dr. Gawande describes the work of one geriatrician, Dr. Juergen Bludau, who had a different approach to medicine. Dr. Gawande recounts observing Dr. Bludau’s first meeting with an older adult patient who had a host of infirmities, which included back pain, arthritis, high blood pressure, glaucoma, a history of colon cancer, and a nodule present in her lung that she was recommended to have biopsied. Dr. Gawande observed that instead of getting fixated on the patient’s plethora of medical concerns, Dr. Bludau turned his attention to the health of the patient’s feet and her ability to take care of them. Dr. Bludau also noted his patient’s physical strength and ability to manage daily activities. The reason he reported giving focus to her feet was that falls are often the precipitant of older adults’ decline. Dr. Gawande writes:

The single most serious threat she faced was not the lung nodule or the back pain. It was

falling. Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end

up in a nursing home, and 20 percent are never able to walk again. The three primary risk

factors for falling are poor balance, taking more than four prescribed medications, and

muscle weakness. Elderly people without these risk factors have a 12 percent chance of

falling in a year. Those with all three risk factors have an almost 100 percent chance

(Gawande, 2014a, p. 40).

By addressing these primary concerns, the patient was able to live with greater independence and quality of life.

      Describing the challenges of nursing homes and finding a better way to implement them, Dr. Gawande writes about meeting with a talented, but wild, physician, Dr. Bill Thomas. Dr. Thomas grew up on a farm in upstate New York, and, after attending Harvard Medical School, he purchased a farm and began working in a nursing home. “Thomas believed that a good life was one of maximum independence. But that was precisely what the people in the nursing home were denied” (Gawande, 2014a, p. 115). He decided to introduce life into the facility where he worked, and he brought to its space 4 dogs, 2 cats, a colony of rabbits, a group of hens, 100 parakeets, a host of plants, and a childcare program. Residents became involved in the care of the animals and plants. Gawande notes:

Researchers studied the effects of this program over two years, comparing a variety of

measures for Chase’s residents with those of residents at another nursing home nearby.

Their study found that the number of prescriptions required per resident fell to half that

of the control nursing home (Gawande, 2014a, p. 123).

Adding novelty and life to the environment, while increasing residents’ power and control, had huge impacts on their health and quality of life.

      Dr. Gawande also writes about the benefits of hospice care, and admits to initially seeing it as a last resort when medicine has failed. He reports a pressure in the medical field, and as a human, to not address mortality, but to try to solve it, even if it decreases one’s quality of life in the process. He describes a change is his perception and reports that hospice is a practice of helping patients have “the fullest possible lives right now” (Gawande, 2014a, p. 161). He addresses the belief that hospice would reduce one’s length of life, but details studies suggesting it does not. He asserts:

In one [study], researchers followed 4,493 Medicare patients with either terminal cancer

or end-stage congestive heart failure. For the patients with breast cancer, prostate

cancer, or colon cancer, the researchers found no difference in survival time between

those who went into hospice and those who didn’t. And curiously, for some conditions,

hospice care seemed to extend survival (Gawande, 2014a, p.178).

He makes an argument that hospice is a beneficial resource many do not employ, but likely should.

      In the audiobook edition of Dr. Gawande's book, he is asked in an interview, “If you had one piece of advice to give all of us about our advancing age, what would it be?” To this, Gawande responds:

We understand that well-being is more than health, and survival, and safety in your life.

We know that already. But it’s okay to insist that our doctors, our institutions, know that

and respect that, as well. I think that’s the most important thing (Gawande, 2014b).

      Dr. Gawande’s book proposes interesting information about the aging process that could potentially help individuals prepare and have greater power and control in their own experience. It should be noted that material in this book addresses medical situations and dying, which could be difficult for some readers. However, Dr. Gawande does well at facing the elephant in room of mortality, to help his readers consider what they and their loved ones might want in the end.

References

Gawande, A. (2014a). Being mortal: Medicine and what matters in the end. Metropolitan

Books.

Gawande, A. (2014b). Being mortal: Medicine and what matters in the end (R. Petkoff, Narr.)

[Audiobook]. Macmillan Audio.

Material on this page is not a provision of therapy and is for informational purposes only. Please meet with a licensed therapist or medical doctor regarding personal health. Regarding my practice, I am only allowed to meet with clients in the states of Ohio and Florida, where I am licensed. If you would like to schedule an appointment with me, I can be reached at #513-848-7268 and catharina@oakscounseling.hush.com.