By weaving individual narratives of hospice care, of age-related medical and care considerations, and of coming to terms with dying and death – in a compelling and meaningful manner, it must be added – with broader history- and socio-cultural-based evaluations of the medical profession and how doctors are trained (or not) to manage age-related frailties and end-of-life medical care as well as statistics-based critiques of ageing and senior living, Atul Gawande’s “Being Mortal: Medicine and What Matters in the End” is an emotional and impactful read: Prompting the reader to think about loved ones who may be struggling with serious illness or who are approaching death, contemplating the type of eldercare one would like to receive, and even considering the types of policies needed.
Across the eight chapters, and drawing upon stories and his interactions with his patients, family, and friends as aforementioned, Gawande speaks to: First, the experience of ageing and confronting death, especially in terms of end-of-life discussions and palliative care; second, the challenges or problems associated with nursing homes, family caregivers at home, and assisted living facilities; and third, anchored by the recurring and “modern” themes of mortality and courage, the roles and responsibilities of medical professionals, and in particular to encourage them to be cognisant of the doctor-patient power imbalance and to respect the agency and autonomy of whom they care for. And in a book full of quotable quotes about the realities of ageing and death, here are some of my more memorable ones:
– The institutionalised nature of eldercare: “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions — nursing homes and intensive care units — where regimented, anonymous routines cut us off from all the things that matter to us in life”.
– The absence of discourse surrounding ageing and death and not emphasising the first-hand needs and desires of those who require the help: “This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals … but never the goal that matters to the people who reside in them: how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore”.
– The focus of medicine on the “repair of health”, but not the “sustenance of the soul”: “For more than half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns … That experiment has failed. If safety and protection were all we sought in life, perhaps we could conclude differently. But because we seek a life of worth and purpose, and yet are routinely denied the conditions that might make it possible, there is no other way to see what modern society has done”.
– The alignment of medical or old-age interventions to “the larger aims of a person’s life”: “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 recognise 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”.
In this vein, and in addition to the observations in “Being Mortal” – such as the shift from multi-generational caregiving to more private arrangements, the fact that the modern nursing home was never (effectively) designed for the elderly facing dependency and that one’s self of autonomy or independence is quickly eroded in this setting (given the three plagues of nursing home existence, “boredom, loneliness, and helplessness”), and the benefits of having end-of-life discussions or “breakpoint discussions” in helping the individual confront the reality of mortality and to subsequently have the courage to act on that truth or reality – one’s reflexivity is constantly exercised, in thinking about personal and systemic improvements for the future. There remains much to be done, in Singapore.