Intimations Of Mortality

Atul Gawande`s Being Mortal (Penguin Books) cuts rather too close to the family bone, so an impersonal review is difficult.

To rage or not to rage against the dying light? That is what the author asks in this book.

Dr Gawande, author of a set of very thought-provoking books like Complications, Better and The Checklist Manifesto, tackles the last phase of life in Being Mortal.  People now live longer and better than any other time in history but scientific advances have turned the process of ageing and dying into medical experiences, and the author has grave misgivings about that. In fighting fast-spreading illness, and seeking more treatment for that, is the patient and the physician pursuing a delusion?

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He uses clear graphs to show how, in earlier times,  life and health would putter along nicely,  then illness would hit and the bottom would drop out like a trap door. Now, with all the treatments for chronic illness, the descent starts to look like less like the cliff of before and more like a hilly road down the mountains with vertiginous drops and also patches of recovered ground, with drugs, fluids, surgery, intensive care to get people through, to make them rally just as they look like they are dying. Then they go home, weaker and more impaired, more vulnerable to minor problems. So medicine carries out its maintenance measures even as the bodily systems crumble. The curve of life becomes a long slow fade.

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Gawande praises the Indian system of elders being surrounded by family. That,  I felt,  was a somewhat roseate view, given the large amounts of old people who live in a state of abject loneliness and depression, and sometimes terrible neglect even in the midst of their family.

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It is an unsettled time, where we have begun rejecting the institutionalised version of ageing and death but the new norms are not yet in place. The new way is a new dance where the physician and the patient try to preserve the fibre of a meaningful life.

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So, medicine cures but does not really make old age better. Nobody really wants to tackle or treat the Old Crock. Gawande throws light on how geriatrics as a demographic as well as in medical departments, are sidelined, and makes a case for palliative care and hospices. 45 per cent of Americans by 2010 died in hospice care, at home and in an institution.

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 Dr Gawande says the unsayable: that terminally ill cancer patients who  were put on a mechanical ventilator, given electric defibrillation, chest compressions or intensive care,  had a substantially worse equality of life in their last week than those who received no such interventions. People`s concerns were  avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden to others and achieving a sense that life is complete. Our system  of technological medical care,   says the author,  has failed to meet these needs. It is important  that we build a health care system that will actually help people achieve what is most important  to them at the end of their lives.

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It’s a double- edged sword, and the reader totally gets the physician`s dilemma. The terminally ill want information, control and guidance. Gawande suggests an interpretive role for physicians to ascertain just what it is that the patient wants, rather than hand them the red or the blue pill. A shared decision- making,  in fact, not paternalistic, not informative but interpretive. But this business of deliberating on one`s options is exhausting and complicated.

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Suffering at the end of life is sometimes unavoidable and unbearable, and helping people ending their lives may be necessary. Gawande is all for this. He also talks of the dying role, where the old want to share memories, pass on wisdom and keepsakes, make peace with god, settle relationships, establish their legacies and make sure those left behind will be okay. They want to end their stories on their own terms.

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 Another very interesting observation from the doctor is that the old don’t fear death as much as they do losing their faculties, their friends, their memory. The Philip Roth quote from Everyman rings harshly true: old age is a massacre. A few die suddenly, most become reduced and debilitated to live alone. More revelations: the aged report more positive emotions than unhappiness. They become less prone to anxiety, depression and anger. Overall, they found living to be a more  emotionally satisfying and stable experience as time passed, even as old age was narrowing their lives down. Living is a kind of skill, the calm and wisdom of old age are achieved over time. And in the end, it has much to do with your perception , the personal sense that your time in this world is finite.

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In between the other cases, Gawande writes of his father`s growing tumour and approaching death in a moving manner.

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Death is the enemy and eventually it wins. And in a  war you cannot win, you don’t want a general who fights to the point of total annihilation, you want a someone who knows how to fight for territory that can be won and how to surrender it when it can`t be won, someone who will not battle to the bitter end. Get real about your illness, that  is the main message here.

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 I have never been a facile writer, the author says.  I don’t know what those authors who describe the words just flowing out of them are talking about. For me, the words come out only slowly and after repeated effort. Which makes the good doctor a man who writes only after much thought. We the reader need to thank him.

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