Being Mortal, Alul Gawande, author; Robert Petkoff, narrator
This is read well by the narrator in a clear appropriately expressive voice for this difficult subject matter. The author very eloquently explains his position on how the elderly are treated. As he leads the reader down the path of life’s possible choices, concerning the actual end of life planning, the idea becomes obvious, but not overwhelming or depressing. He exposes the truth. Everyone is on the path of life, a path that dead ends, unstoppably, with no alternative, or as my brother would say, we all have an expiration date and life is a terminal illness. It is important to figure out how to handle the end of that road in the best possible way, so we live until the day we die without contemplating death, unduly, in such a way that we stop living because of it.
What heroic measures would we want to be taken to keep us alive? How many of us would choose machines performing our bodily functions while we lie in a vegetative state, not truly living at all, just breathing? Should the choice for medical intervention be entirely up to the patient, the proxy, the legal guardian, the medical professional, or a combination of all those involved? Is it wise to simply keep the body alive even when there is no cognition, no mind or matter functioning and no hope for recovery.
The author explains the progression of elder care, and while it has succeeded in improving somewhat, it is on its way to returning to its original state of treating aging as a disease, rather than a fact of life. In treating the elderly, often their independence and decision making power is removed making them totally dependent on others when they would rather be on their own, in their own familiar surroundings, their own home until they die. Of course, this wish is expensive today. In the past, before modern technology which extended life enormously, family and friends lived nearby and assisted the elderly to cope and function. Today, everyone is off on their own, fighting for their own time and independence. Today, the elderly often have elderly children who wonder when their time to enjoy their life will come. Outside help must be engaged to assist them.
Dr. Gawande gives examples of group type homes that do work since the residents have freedom to be useful adults again. He is opposed to the nursing homes that place the emphasis wholly on safety and maintaining a healthy weight for the patients. Their mental health is rarely considered. These people are dying, they will not recover, old age is inevitable and so is the eventual infirmity that comes with it, so, why are the elderly forced to actually exist in a kind of living death (my words not the authors), in the facilities that provide their care? Why are they forced to follow such a structured life, one that they had no part in designing? Their loss of autonomy often hastens their death.
This doctor/author clarifies the idea that aging is a natural event, and although we might be able to delay its arrival and some of the symptoms, they will all eventually occur. We will all have to deal with diminished sight, loss of hearing, frailty and memory impairment to some degree. He believes there has to be a better way to treat the elderly than to line them up in hallways so the rooms can be cleaned, to force them to eat on a uniform schedule whether hungry or not, and to prescribe treatment and drugs unnecessarily. He believes that the elderly can and should live in places that maintain their usefulness and will to live until they die, not places that simply act as caretakers until they do die. Why would anyone have the will to live in such a place? It is the most feared end for most of us besides the actual fear of dying alone, besides the fear of the pain and suffering that might accompany our end.
Through his personal experience and investigation, Dr. Gawande exposes some of the reactions of the elderly to their diagnoses of impending death due to illness, and of their expectations concerning a healthy aging process. He presents a clear picture of what is wrong with our treatment of seniors and the infirm, although the solution he presents is not as clear cut because, at present, there are few places that provide the kind of lifestyle he envisions for them. He believes that doctors have not been taught and therefore do not know how to help patients deal with the prospect of dying in a healthy way or with terminal illness. He believes that the elderly feel useless and it would be better if a society could be created for them where they would coexist and continue to handle responsibility, each according to his/her own ability. We will all die eventually and we would all like to die without suffering and with dignity. This is not possible yet, today, although in some cases, Hospice is changing the horror of a frightening and/or painful death and is evolving and dealing better with some of these concerns.
There are horror stories everywhere as well as success stories too. Surgeries and treatments are chosen to add years to the life of a patient, but instead they end it prematurely. Patients choose futile treatments to give them more time to live, but wind up merely existing, not living, mostly because of the advice of a doctor who is untrained in the art of discussing dying and so is unwilling to be totally honest and direct, telling the patient he will most certainly die, and instead offers up ideas of treatment which might prolong life but at the cost of actually having a quality of life. When is palliative care the right choice and who gets to make that decision for the patient, the patient or the medical world? If a doctor is not completely truthful with the patient and in order to protect the patient from the absolute truth the doctor does not say, yes, you are certainly dying, when questioned, and does not advise the patient that they can be kept pain free and comfortable to enjoy the time left, if the doctor does not say that treatment will not forestall the ultimate conclusion, then how can the patient make a rational decision about their end of life. The author believes that doctors soften their diagnoses to protect the patient from the difficult truth. When they ask if they are going to die, they are told no, there are ways to help, but they are not bluntly told that there is no cure, no chance of a full recovery. There will only be a continual decline. The patient thinks he is being given an opportunity to live many more years while it may only be months or less in the doctor’s mind, depending on the outcome of whatever medical intervention they choose. He emphasizes that we are all going to die and so is that patient trying to make a decision about how to go forward and while some patients do need hope more than total honesty, largely because there is no good way to die today, false hope completely fails to help the patient or the medical environment.
He provides this description of the evolution of elder care: it went from home, to hospital, to nursing home (created to relieve hospitals from the number of patients), to independent living, and then to assisted living facilities that were actually doing the job he suggests, providing the elderly with a life rather than an environment that only anticipates death. Unfortunately, the profit motive has altered the original purpose of these places and as they have gained recognition and big corporations have gotten involved, the assisted living facilities that concentrated on the well being of the elderly in body and mind have gotten larger, more efficient and therefore less caring. They are beginning to more and more resemble the nursing homes they were designed to replace. They are beginning to treat the elderly as medical cases again, not simply as human beings who are naturally weakening in some ways as they age. Of course, the demand for increased services may also be a result of patient concerns and family needs. The elderly today seem to have relinquished the responsibility for their own well being to their children, essentially reversing the natural order of things; the elderly become the children of their children, sometimes even their elderly children. Therefore, once again, the responsibility for their care is being shunted to the expedient administrative needs of institutions that house them, rather than to their human needs. Seniors become bored, lonely and helpless. That is the illness of growing old that must be addressed. It is not a medical issue, it is an aging issue. The elderly do not want to give up their freedom or their autonomy. When they do, they are sedated in nursing homes, forced to go to the bathroom on a schedule, eat on a schedule and bathe on a schedule.
All of us have witnessed older people treated deferentially or ignored completely, considered “less than” and this is everywhere, not just in nursing homes or hospitals. To some, they are simply not worth the effort. They are, after all, close to death; the expense and effort expended for their care seems futile and a waste to some people. The doctor writes about the survival rates of patients suffering from certain illnesses. He talks about the age at which certain parts of the body begin to decline, hearing, sight, agility, strength. These things simply will happen. They may be forestalled but cannot be prevented.
He is a surgeon and if he feels the patient should concentrate more on living well in the time he has rather than on the time he has left, if he feels medicine is not the only answer, perhaps we should take notice, sit up and listen. He believes that there have to be better alternatives to offer to the patient, medical and otherwise, that the doctor has to be more truthful in explaining the prognosis, in explaining the chances of recovery or cure as opposed to simply maintaining the status quo, that the facilities have to consider the person, not just the body, and I, for one, would like the be told the truth, but told in a gentle, caring manner that does not sound like a death sentence, but rather, a term limit which we must all deal with and face in the end.