Being Mortal by Atul Gawande
Judging from how long it took me to get my hands on this book, Being Mortal is one of the hottest books on the market right now. Not surprising, given its 5 star rating based on over 1700 ratings on Amazon. It also focuses on an increasingly popular and ironically trendy topic – aging – if only because it’s becoming relevant for an ever increasing portion of the population.
What I didn’t expect was how emotional this book is. I think everyone who reads this will naturally think about their grandparents and parents. Have they gone through end-of-life care? What were the difficult choices that the family had to make? And I also thought about myself. What do I want when I’m old and not capable of taking care of myself? I have the benefit of hoping that medical advances will have solved much of the problem when I get to that stage, but I wouldn’t say that’s a realistic expectation.
Ultimately, Being Mortal tackles the dilemma of providing care that would prolong life at all costs versus providing care that would make life – however long – worth living. To answer this question, we must know what people actually want as their life winds down. How do we do that?
1) Del Webb, an Arizona real estate developer, popularized the term “retirement community.”
In 1960, he launched Sun City in Phoenix exclusively for retirees.
2) By 85, 40% of people in industrialized countries have no teeth.
This is the most astonishing of many scary numbers. Over 50% develop hypertension by 65. 25-50% of muscle weight is gone by 80.
3) The most dangerous thing that can happen to an elderly person is falling.
Each year, 350,000 Americans fall and break a hip. 40% end up in a nursing home, and 20% can never walk again. Gawande focuses on the slippery slope of falling. It signals loss of body control and usually leads to complications that never go away.
4) Nursing homes came about as a solution to hospital overflow.
Before WWII, hospitals were just a place to stay. Being in a hospital did not mean that you got better medical treatment than at home. After WWII, with medical advances, this changed. The Hill-Burton Act of 1946 financed 9000 new medical facilities in America. Meanwhile, the establishment of Social Security did not stop the elderly from ending up in poorhouses. The extra income was ineffective at solving end-of-life medical problems. Thus, the sick elderly ended up in hospitals. After some lobbying, in 1954, hospitals were allowed to build custodial units for people who needed time for recovery. The nursing home was born. Then, when the “substantial compliance” threshold was created for Medicare coverage, nursing homes were approved as facilities where care for the elderly would be covered. By 1970, there were over 13,000 nursing homes.
5) Home is where you decide how you spend your time, how you share your space, and how you manage your possessions.
Home is about you. You make the decisions. If you’re omnipotent, I guess the world is your home.
6) Keren Wilson started assisted living around 1990. Her company Assisted Living Concepts went public.
By 2010, the number of people in assisted living and the number of people in nursing homes were comparable. However, the term assisted living has definitely morphed and is somewhat used today to market to people who try to avoid nursing homes at all costs.
7) Doctors often overestimate how long their patients will survive.
According to one study, the average estimate was 530% too high.
8) An MGH study showed that palliative care extends life and has additional benefits.
They had 151 patients with stage IV lung cancer. Half got the regular oncology care. The other half got that plus visits with a palliative care specialist. The second group stopped chemotherapy sooner, entered hospice earlier, reported experiencing less suffering and lived 25% longer. In fact, hospice is becoming a very popular choice – with 45% of Americans dying in hospice. People used to die in homes, then they died in hospitals/nursing homes. Now they are going back home.
9) Daniel Kahneman writes about the Peak End rule in Thinking, Fast and Slow.
People tend to focus on the best/worst moment and the last moment.
10) According to Hindu mythology, when a person’s remains touch the Ganges River, they achieve eternal salvation.
Therefore, many people spread ashes into the river. Gawande was told to drink some of the water as part of the process and came down with an infection.
The end of life is scary. You can no longer make decisions for yourself. Your body doesn’t listen to you. Your family might not listen to you. The last thing you need is for your doctor to not listen to you. Gawande is a great storyteller. The book follows individuals with unique needs and situations – illustrating everything that he thinks is wrong about how end-of-life care is done right now.
One aspect that he didn’t touch on as much, perhaps intentionally, was the financial incentives. However, he did briefly mention the ramifications of having patients pay and the fact that doctors get paid for chemotherapy but not for discussing alternatives with their patients. I’m not well informed on how fee-for-service works with Medicare and what direction it’s going, but I’m certain that finance plays a big part in how things are done right now. From the incentive to keep trying different treatments to the cost benefit tradeoffs of living at home vs a nursing home, money drives a lot of decisions. It would be great if Gawande could write another book on that. I’m sure it would be a best seller.