This book tackles the topic of death and aging and how modern medicine is failing us towards the ends of our lives. It’s hard and depressing to read (especially the stories of the inevitability of the body breaking down, aging, and death), but that’s why it’s all the more important to do so.
The book is extremely well written and researched and Gawande does a superb job at tackling very difficult topics including aging, dying, and even the meaning of life itself. It’s a rare book that can make a profound difference in your life, but as you and your loved ones grow older, the advice and questions in this book could make all the difference.
There are some powerful insights here:
Where you die
- Die at home. Through most of human history, people died in their homes, with their families around them.
- Die in senior living centers. The idea of shipping someone off to a nursing home or hospital at the end of their lives is a new one, and we’re still figuring out how to do it well.
Gawande discusses the different types of senior living available:
- Nursing homes
- Hospice
- Home care
- Assisted living
There are many variations and levels of quality within each one. I have to admit I had never thought about any of these options, but anyone with sick or elderly relatives needs to understand the differences between these, as they make a profound difference in people’s lives.
End-of-life treatments
Modern medicine has given us countless tools for trying to prolong someone’s life, but sometimes, those tools make life worse, with little possible gain.
- Towards the end of someone’s life, we often push for the most aggressive treatments possible: e.g., chemo, radiation, surgery, etc.
- These treatments typically have a low probability of significantly extending life: e.g., a year at most, whereas the patient is hoping for 10-20.
- These treatments typically have a high probability of increasing suffering.
As Gawande says, we are offering people the medical equivalent of a lottery ticket: something with extremely low odds of success, but a very high price.
Keeping someone alive
Modern medicine has advanced so far, that much of the way we discuss death no longer makes sense.
- We have machines available that can replace the function of many of the body’s organs—kidneys, heart, lungs—and can keep someone “running” for long periods of time.
- Rarely is there “nothing more” a doctor can do.
- But is keeping the body functioning—is keeping the machine “running”—the same as keeping someone alive?
- Gawande isn’t arguing for assisted death, but quite the opposite: on figuring out how to live the final stages of your life better.
How to discuss this
What makes this situation harder is that many medical professionals are not well-trained in how to discuss death and suffering with patients. It’s a brutally hard conversation to have, but if you don’t have it, then you may not be giving the patient what they really want.
The main conversation that doctors need to have with patients, as well as family members with their sick or dying relatives, is to ask several hard questions:
- What is your understanding of the situation and its potential outcomes?
- What are your fears and what are your hopes?
- What are the trade-offs you are willing to make and not willing to make?
Some examples:
- One patient in the story was willing to undergo anything, so long as he could still eat ice cream and watch TV.
- A different patient was not willing to live such a lifestyle, and only wanted to do procedures that would allow him to keep walking and living independently.
Instead of a “treatment at any cost” philosophy, which can make the final stages of life unbearable—and in some cases, actually shorten the time you have left—Gawande’s approach is all about figuring out what the person really wants and to pick a course of action that gives them the best chances of that.
Side note: the role of the elderly has changed
In many societies of the past, the oldest members:
- Were venerated
- Held the highest positions of power
- Were deeply respected for their knowledge and wisdom
This is more rare nowadays because:
- Growing old isn’t nearly as rare
- Knowledge is easier to come by (e.g., thanks to books, the Internet, smartphones, etc.)
- Society is changing so rapidly now, that knowledge from a just a few years ago is often already obsolete
Quotes
As always, I’ve saved some of my favorite quotes from the book (though to be honest, I could’ve saved half the book):
In the end, people don’t view their life as merely the average of all its moments—which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people’s minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.
A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.
Our ultimate goal, after all, is not a good death but a good life to the very end.
All we ask is to be allowed to remain the writers of our own story. That story is ever changing. Over the course of our lives, we may encounter unimaginable difficulties. Our concerns and desires may shift. But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties. This is why the betrayals of body and mind that threaten to erase our character and memory remain among our most awful tortures. The battle of being mortal 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.
The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society.
