Being Mortal
Notes on Atul Gawande’s book
Notes
Introduction
- Idea: mortality should not be a medical experience in the vein of medical experiences to date, because doctors haven’t been properly prepared to deal with no-win situations.
- “There’s always a way,” children’s books and movies teach you. You often read about people succeeding, stories of hope, pulling off plans against all odds. But this is the other side. This is about coping with the no-win scenario of inevitable death.
- Informal writing style, which feels (along with a lot of modern popular nonfiction books) like an extended, written TED talk or something that could easily become a TED talk.
Chapter 1: The Independent Self
- The internet has supplanted elderly wisdom when it comes to passing on information. You can learn about the past, about tradition, or about how to do things without an elder’s help.
- It is no longer rare to be old due to advances in health maintenance and medical treatment.
- When people have the economic means to live independently, they choose to. The elderly choose “intimacy at a distance” instead of living with their children. The problem is, you can’t be independent forever. So what happens when you’re not?
- Due to intimacy at a distance, the independent elderly now share status and control with the younger generations. Veneration of the elderly has been replaced by veneration of independence.
- Contrast between Western and Eastern cultures in terms of approaches to elderly living situations (Western cultures more likely to establish intimacy at a distance; Eastern cultures more likely to maintain multigenerational households and intimacy not at a distance).
Chapter 2: Things Fall Apart
- A doctor’s job is to support “quality of life”.
- Felix Silverstone’s purpose becomes taking care of his wife when he is old (based on Man’s Search for Meaning, he finds meaning in experiencing a love for others).
Chapter 3: Dependence
- Progression from poorhouses to modern elderly living facilities occurred as a result of (1) aging being seen as a medical problem, and (2) the rapid advance of medicine, s.t. it could actually somewhat reliably keep people alive.
- People were putting the elderly in hospitals for extended periods of time, which prompted the creation of nursing homes. The point of nursing homes was ultimately to clear out hospital beds, and of course to keep people alive, but not to keep them purposeful or anything like that. Nursing homes were not created with the elderly in mind as humans.
Chapter 4: Assistance
- Assisted living vs. nursing homes – apartments with closed, locked doors vs. hospital-like beds with only a modicum of privacy. Assisted living is like living in an apartment where you can summon help immediately from on-site staff. In nursing homes they institutionalize you and have you live according to a schedule set by others.
- Idea from Cartensen: we choose how we spend our time (broadly or narrowly, exploration or exploitation, doubloons or victory points) based on how much time we think we have left.
- Capitalism strikes again: people turned the concept of assisted living into an opportunity for profit, which required a decrease in freedoms out of fear of lawsuits. Much of the original idealism was lost, and assisted living facilities became cheap/ineffective stops on the continuum of care between independent living and nursing homes.
- We don’t have a precise way to quantify things like loneliness, so they are deprioritized by the people in charge of elderly living facilities in favor of quantifiable things like weight gain/loss, whether people are taking their medications, number of falls, etc.
- Elderly facilities end up being built for the sake of (and to appeal to) the children rather than their elderly parents. “We want autonomy for ourselves and safety for those we love.” Goes for families, friends, SOs, etc. Good quote.
Chapter 5: A Better Life
- Bill Thomas: a self-sufficient guy who wanted to attack the Three Plagues of nursing home existence (boredom, loneliness, and helplessness) by injecting life into them – adding live plants, animals (two dogs, four cats, 100 birds), and children (staff members’ kids) in one case. Idea: turn boredom into spontaneity, loneliness into companionship, and helplessness into responsibility + the ability to care for another living being.
- Released 100 parakeets into the interior of the nursing home, closed the door, and left. :)
- Results: residents needed less medication, deaths down by 15%.
- Originally aging was the concern of medicine; we gave no thought to what made life significant as an elderly person. Keeping people safe and alive was all that seemed to matter. But people (the elderly included) don’t just seek safety; people seek worth/purpose too. We must sustain the value of existence for the elderly.
Chapter 6: Letting Go
- Things that are important to people at the end of their lives: avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, achieving a sense that one’s life is complete.
- Ordinary medical care vs. hospice: ordinary care extends life at the cost of quality of life. Hospice aims to give people the fullest possible lives (reduction of pain, palliative care, maintaining mental awareness), whether or not the ultimate lifespan is longer or shorter.
- Live for now, or sacrifice for the future?
- Ironically, hospice care seems to extend life to a greater degree than ordinary care. “You live longer only when you stop trying to live longer.”
- Somehow having the discussion of what is important to you at the end of life EARLY ON, or at least before the real problems start, seems to increase longevity.
Chapter 7: Hard Conversations
- Three stages of medical development that countries go through: (1) extreme poverty: most deaths occur in the home, (2): developing economy: die in the hospital instead of at home, (3): high-income country: people have the means to care about quality of life in sickness, and more deaths occur at home (with hospice care) again.
- Styles of doctor-patient relationships: (1) paternalistic: doctor in charge, makes the decisions, (2) informative: give patient information, let him/her make the decisions, (3) interpretive: something in the middle, guide/counsel – make the decision together.
Chapter 8: Courage
- Peak-end rule: primarily remember the suffering over some duration/experience by the peak amount of pain, and by the amount of pain at the end of it. Same with pleasure and most other sensations? The peak of the feeling is maybe the most important for the remembering self, no matter the duration.
- Experiencing self: how you feel while doing/experiencing something.
- Remembering self: how you think about it afterward.
Discussion Questions
- Any personal stories about death/mortality that you feel able to share?
- [Introduction] What do you think you would choose if you were in Lazaroff’s position? Comfort care or surgery? Say the surgery could either cure you without introducing any new complications, or do what it did to Lazaroff. What stated odds would compel you to take it? Would you risk it on a 50% chance that you were cured? 1%?
- How would you choose to die? When you were saving the world? When you were asleep, to avoid pain? When you were surrounded by your friends? What is your “dream death”?
- How would you want to live if you were old and in need of day-to-day help? Would you adopt a parakeet? Do you think you would expect or want to move in with your children?
- Eastern culture tends to have a tradition of the elderly moving in with the whole family. In what ways do you think this is preferable to the American nuclear family setup?
- What do you think about retirement homes? How has this book changed your opinions?
- What are your ideal assisted living conditions, if you could determine them completely (e.g. super-cool high-tech smart home)? Have you ever visited an assisted living or nursing home?
External Discussion Questions