Author: Atul Gawande
This book is a powerful but sensitive critique of what it calls ‘the modern experience of mortality‘. The author, a well-known surgeon and writer, explores the harm and discomfort inflicted by the way aging and dying have been transformed into a technological and custodial medical experience (pages 9 and 85). The book is a compelling attempt to draw attention to the needs and concerns of the old and dying who, the author says, ‘do not ask for much… they ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world’ (pages 146-147). The book is largely autobiographical, and the themes it explores are greatly influenced by the terminal illness and eventual demise of the author’s father and mother-in-law, experiences he relates with much warmth and tenderness.
The author’s main focus is the ageing process, something he describes as ‘the accumulated crumbling of one’s bodily systems’ which happens imperceptibly, like the creeping of a vine (pages 28 and 42). With reference to researcher Leonid Gavrilov, he compared human frailty to the random and gradual failure that all complex systems experience, leading to the inevitable end when ‘just one more defect is enough to impair the whole’ (pages 33-34). He illustrated the devastating impact of aging on the body with the haunting story of geriatrician Felix Silverstone who ‘noticed that his skin has dried out…his sense of smell was diminished…his night vision had become poor, and he tired easily’ (page 48).
The author dedicated a great part of the book to the need to give old people enough purpose to maintain their integrity. He regretted how, in modern societies, old age is ‘something experienced largely alone or with the aid of doctors and institutions‘; he compared this to the multi-generational system in India which enabled his own elderly grandfather ‘to maintain a way of life’ and ‘to cope with the infirmities of age‘ (pages 15-17). He acknowledged that it is impossible to go back to the older ways, but he did not think nursing homes, the prevailing alternative, ‘address goals that matter to the elderly’ (pages 72 and 77). He therefore explored alternatives such as assisted living which, quoting pioneer Karen Brown Wilson, are places where ‘ordinary people can age without having to choose between neglect and institutionalisation‘ (page 103). Other innovative options include physician Bill Thomas‘s bold approach to eliminating ‘the three plagues of nursing home existence: boredom, loneliness, and helplessness‘ (pages 115-125).
A major concern the book addresses is the narrow focus with which the institution of Medicine approaches death. The author supports this view with his personal experience that medical students are not taught about death, and ‘our textbooks had almost nothing on aging or frailty or dying‘ (page 1). He urged doctors to understand that ‘people with serious illness have priorities besides simply prolonging their lives, and these include avoiding suffering and strengthening relationships (page 155). He cautioned doctors, when they manage the ‘the frail and dying‘, to resist the urge ‘to fiddle and fix and control‘, and to recognise when to act, and when to hold back (page 149). The book advocates the training of more geriatricians (pages 37-43), and discussed many palliative care concepts such as prognosticating (page 167), hospice care (page 177), advance directives (179-180), shared decision making (page 201), and assisted dying (pages 244-245). It also offers helpful and insightful tips to negotiate difficult end-of-life conversations (pages 182-183 and 206-207).
The author projected a very healthy and philosophical view of death, describing it as our fate and ‘the natural order of things’ (pages 8 and 44). He metaphorically refers to death as an ‘enemy with superior forces which eventually wins’ (page 187). Faced with this overwhelming odds, he argues that the challenge for mortals is ‘the battle to maintain the integrity of one’s life-to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be’ (page 141). Being mortal, in his opinion, is to end life meaningfully by being ‘part of something greater: a family, a community, a society‘ (page 127).
The author enhanced the book with many references to non-medical sources. He refers, for example, to psychologist Laura Cartensen and her socioemotional selectivity theory which relates to what makes life worth living (pages 92-98). He uses Leo Tolstoy‘s fictional story, The Death of Ivan Ilyich, to illustrate the simple needs of people approaching their mortality, and the inability of those around to provide this (page 99). He referred to philosopher Josiah Royce who showed that ‘we all require devotion to something more than ourselves for our lives to be endurable‘ (pages 125-126).
In his usual style, the author has addressed an issue that is rarely highlighted, and he did this by beautifully weaving in his personal experience and interesting anecdotes. His usual unimpeachable writing style was evident throughout the book. His excellent prose clearly made the difficult topic of death easy to read and appreciate. His views on the care of the old and dying are timely, and all the issues he discussed raised fundamental questions for healthcare.
The book emphasises the inadequacy of medical training to deal with subject of death. It also pointed out the inadequate systems that are in place to deal with the rising number of the elderly and infirm. The author addresses issues which are currently at the periphery of medical practice, and he emphasised their central importance to the future of Medicine. The book explains the why death matters to medicine, and I recommend it to all doctors.
Publisher, Place, Year: Profile Books, London, 2015
Number of chapters: 8
Number of pages: 282
Star rating: 5