Being Mortal by Atul Gawande

The writing is simple; the subject emotionally overwhelming. The book eases the reader into life's grim realities we all have to contend with—old age, disease, decrepitude, and death. If suffering is likely to precede death and, in those final stages, you are expected to make tough decisions for yourself or on behalf of  your loved ones, you would do well to read the book.

The author speaks to the medical fraternity and to those who look up to it to fight mortality. A targeted medical intervention or a technically successful surgery may bring professional/academic satisfaction to the medical practitioner, but for the terminally ill or those in their ripe old age, it usually comes at the cost of autonomy and quality of life. This hardly concerns the doctor if he is able to fix up the 'actual' problem. The doctor treats the patient’s problem as a challenge to his competence and speaks with the pride of a qualified medical practitioner. To his patients, he gives an objective estimate of outcomes, equating the chances of walking out of hospital on one's feet with the toss of a coin. The patient mentally stacks up the odds in his favour as if he is undergoing a cosmetic surgery.  

The success on the surgery table does not always translate into a life of dignity for the patient. The effort usually results in adding years to life rather than adding life to years. A few extra years come with a lonely life in an infrequently visited corner of the house, bed-wetting embarrassments, choking on food, and groggy days from ingesting pain-killers. We witness such helplessness in others and promise ourselves not to go down the path of seeking a medically-assisted vegetative state. But, it's difficult to stick to the resolve when death comes knocking at our door. We would cling to life at all costs if only the doctor would offer us a glimmer of hope. We would give little thought before giving away our autonomy into the hands of caregivers who from then on restrict our waking hours, eating time, and even movement.

Decades ago, the elderly led a life of independence well into their final days. The entire family became natural caregivers to them and put up with their eccentricities. Someone was always available to provide company and felt obliged to bid their word even if that meant taking them to a distant village to attend the wedding of a great grandson. They died among their kinsmen and not in a nursing home (hospice). Nuclear families go through a vexing time in caring for the old, not to speak of the drain on finances. Later, nursing homes intensify the anguish of losing independence and thus become prison houses for the old.  

Between allowing that one candy to a 90-year-old and preventing sugar levels from rising, the choice that a nursing home or a professional caregiver would make is pretty obvious. One whose life is already physically so circumscribed, denying him a simple pleasure, which could mean life to him, does more harm than good. One who had always dressed to the nines to be clad in an ill-fitting gown is akin to stripping her of her dignity. The author offers a go-between. For that, you must read the book.

The author rightly suggests that it is in the best interest of the family to talk to their ailing elders of their expectations for the sunset years, their fears (of not being able to conduct themselves the way they would want to), and the trade-offs they are willing to make by opting for a certain line of treatment/surgery, and at what point they would want to stop medical intervention. We in turn must convey this to our loved ones instead of making it difficult for them to have this conversation. 

Geriatrics is an unglamorous choice for medical students. No one wants to make a career out of interacting with sloppy, garrulous, forgetful, and grumbling old men. One with numerous health issues is a no-win situation. Even in the US, the number of geriatric doctors is much below the required number. The replacement rate for retired geriatrics is also negligible. The retired ones are themselves in need of senior-care doctors! Imagine the situation in India. What happens when the demographics of India shifts to an older age population. If we leave out high-end assisted-living facilities, old-age homes in India are one of the most heart-rending places on earth. We assume that people go their to die; sometimes abandoned to die there.

I hope I haven't spoilt your day. I had decided to no longer review books. The time could be better spent reading other books. But, I made an exception for this one.  

The author is a practicing physician and narrates a personal account of confronting his father’s failing health leading up to his death. He gives us clues to the kind of conversation one must have with the doctor when discussing options one is left with. The book is a very compassionate account of a doctor dealing with mortality and how we can make things better for the elderly. Mortality is mortifying. Like seasons, it is an ever-present fact. We make better choices for ourselves and others when we accept it. And, just because old age is a sure sign of mortality, it need not be a phase of self-rejection. 

My lesson from the book: Retire early and have a life before all dreams come crashing down 😀