Being Mortal - Atul Gawande

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In Being Mortal, Atul Gawande writes a thoughtful and deeply personal reflection on mortality that weaves narrative and analysis seamlessly in order to present a cogent, urgent argument as to why we need to change the way we, as a society, think about dying.

The fundamental problem that Mr. Gawande presents is that in today's modern-medicine-enabled society, it is almost universally believed that we must do whatever it takes to extend life -- even if doing so reduces somebody's overall quality of life. Doing otherwise would be 'giving in to death', and that's blasphemy, cultural anathema as egregious as denying the existence of climate change.

However, when you consider the two relevant parties when people are nearing their expiration date, it is immediately clear that the result is suboptimal. Picture it: on one side you have doctors who only have experience to gain out of performing more and more extreme procedures, and on the other you have the dying patients who pay only a small portion of their total (outrageous) hospital bill*. The result is large amounts of money thrown at marginal increases in longevity, and most often, disastrous decreases in quality of life.

Mr. Gawande brings us to realize that "what is most important to you?" is a question all doctors should ask their terminal patients, and that should the patients answer "living longer", the doctor should continue to interrogate them. Because almost in every case, living longer is only a means to a different end. The real answer is often "I want to spend my last few moments with my family / I want to die with dignity / etc."

There is clearly a conflict of interests, and as Gawande succinctly puts it "most [doctors] have no appreciation that … doing too much could be no less devastating to a person's life."

Psychology courtesy of Daniel Kahnemann is relevant here: the Peak-End rule, which applies to people's remembering selves, means that they "give almost all the weight of judgement afterward to two single points in time, the worst moment and the last one." (p. 237) Considering this would you rather spend the last two weeks of your life in assisting living with a healthy drip of painkillers or cycling daily between extremely painful consciousness and extremely nerve-wracking (for your family) unconsciousness in the ICU.

*insurance of course pays the rest, and this leads to its own host of problems


Misc. findings:

  • Nursing homes were designed to empty hospital beds, not cater to a dependent aging population. "in 1954 lawmakers provided funding to build separate custodial units for patients needing an extended period of "recovery." (p. 71)

  • Stanford psychologist's Laura Cartensen's 'Horizon theory' that when horizons are measured in decades, people desire all the stuff at the top of Maslow's pyramid, but as horizons contract (when you think you're going to die), your focus shifts to everyday pleasures and the people closest to you.

  • In the US, 25% of all Medicare spending is spent on 5% of patients who are in the final year of their life

  • In a study (Christakis 2000) doctors were asked to estimate the longevity of 500 terminally ill patients. 63% of them overestimated, and the average estimate was 530% too high

  • More than 40% of oncologists admit to offering treatments they believe are unlikely to work

  • Landmark 2010 study from Massachusetts General Hospital showed that participants who received visits from a palliative care specialist in addition to usual oncology care ended up living 25% longer -- sample size: 151 patients with stage IV cancer


On aging (p 34-35)

     [Aging] happens in a bewildering array of ways. Hair grows gray, for instance, simply because we run out of pigment cells that give hair its color. The natural life cycle of the scalp's pigment cells is just a few years. We rely on stem cells under the surface to migrate in and replace them. Gradually, however, the stem-cell reservoir is used up. By the age of fifty, as a result, half of the average person's hairs have gone gray.

     Inside skin cells, the mechanism that clear out waste products slowly break down and the residue coalesces into a clot of gooey yellow-brown pigment known as lipofuscin. These are the age spots we see in skin. When lipofuscin accumulates in sweat glands, the sweat glands cannot function, which helps explain why we become so susceptible to heat stroke and heat exhaustion in old age.

     The eyes go for different reasons. The lens is made of crystalline proteins that are tremendously durable, but they change chemically in ways that diminish their elasticity over time -- hence the farsightedness that most people develop beginning in their fourth decade. The process also gradually yellows the lens. Even without cataracts (the whitish clouding of the lens that occurs with age, excessive ultraviolet exposure, high cholesterol, diabetes, and cigarette smoking), the amount of life reaching the retina of a healthy sixty-year old is one-third of a twenty-year-old.

     I spoke to Felix Silverstone, who for twenty-four years was the senior geriatrician at the Parker Jewish Institute, in New York, and who has published more than a hundred studies on aging. There is, he told me "no single, common cellular mechanism to the aging process." Our bodies accumulate lipofuscin and oxygen free-radical damage and random DNA mutations numerous other microcellular problems. The process is gradual and unrelenting.

     I asked Silverstone whether gerontologists have discerned any particular, reproducible pathway to aging. "No," he said. "We just fall apart."