Notes & Quotes: Being Mortal by Atul Gawande

The following are my favorite notes from Atul Gawande's Being Mortal: Medicine and What Matters in the End.
  1. As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did. Those who somehow did die at home likely died too suddenly to make it to the hospital -- say, from a massive heart attack, stroke, or violent injury -- or were too isolated to get somewhere that could provide help. Across not just the United States but also the entire industrialized world, the experience of advanced aging and death has shifted to hospitals and nursing homes.
  2. For most of our hundred-thousand-year existence -- all but the past couple of hundred years -- the average life span of human beings has been thirty years or less. (Research suggests that subjects of the Roman Empire had an average life expectancy of twenty-eight years.)
  3. The risk of a fatal car crash with a driver who's eighty-five or older is more than three times higher than it is with a teenage driver.
  4. In 1954 lawmakers provided funding to enable them to build separate custodial units for patients needing an extended period of "recovery." That was the beginning of the modern nursing home. They were never created to help people facing dependency in old age. They were created to clear out hospital beds -- which is why they were called "nursing" homes.
  5. 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 -- from freeing up hospital beds to taking burdens off families' hands to coping with poverty among the elderly -- 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.
  6. Your chances of avoiding the nursing home are directly related to the number of children you have, and, according to what little research has been done, having at least one daughter seems to be crucial to the amount of help you will receive.
  7. Their attitude seemed to result from incomprehension rather than cruelty, but, as Tolstoy would have said, what's the difference in the end?
  8. So this is the way it unfolds. In the absence of what people like my grandfather could count on -- a vast extended family constantly on hand to let him make his own choices -- our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.
  9. The inhabitants of Chase Memorial Nursing Home now included one hundred parakeets, four dogs, two cats, plus a colony of rabbits and a flock of laying hens. There were also hundreds of indoor plants and a thriving vegetable and flower garden. The home had on-site child care for the staff and a new after-school program. Researchers studied the effects of this program over two years, comparing a variety of measures for Chase's residents with those of residents at another nursing home nearby. Their study found that the number of prescriptions required per resident fell to half that of the control nursing home. Psychotropic drugs for agitation, like Haldol, decreased in particular. The total drug costs fell to just 38 percent of the comparison facility. Deaths fell 15 percent.
  10. In 1908, a Harvard philosopher named Josiah Royce wrote a book with the title The Philosophy of Loyalty. Royce was not concerned with the trials of aging. But he was concerned with a puzzle that is fundamental to anyone contemplating his or her mortality. Royce wanted to understand why simply existing -- why being housed and fed and safe and alive -- seems empty and meaningless to us. What more is it that we need in order to feel that life is worthwhile? The answer, he believed, is that we all seek a cause beyond ourselves. This was, to him, an intrinsic human need. The cause could be large (family, country, principle) or small (a building project, the care of a pet). The important thing was that, in ascribing value to the cause and seeing it as worth making sacrifices for, we give our lives meaning...Royce called this dedication to a cause beyond oneself loyalty. He regarded it as the opposite of individualism. The individualist puts self-interest first, seeing his own pain, pleasure, and existence as his greatest concern. For an individualist, loyalty to causes that have nothing to do with self-interest is strange. When such loyalty encourages self-sacrifice, it can even be alarming -- a mistaken and irrational tendency that leaves people open to the exploitation of tyrants.
  11. The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society.
  12. As our time winds down, we all seek comfort in simple pleasures -- companionship, everyday routines, the taste of good food, the warmth of sunlight in our faces. We become less interested in the rewards of achieving and accumulating, and more interested in the rewards of simply being.
  13. Those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives -- and they lived 25 percent longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.
  14. The brain gives us two ways to evaluate experiences like suffering -- there is how we apprehend such experiences in the moment and how we look at them afterward -- and the two ways are deeply contradictory.
  15. Everyone knows the experience of watching sports when a team, having performed beautifully for nearly the entire game, blows it in the end. We feel that the ending ruins the whole experience. Yet there's a contradiction at the root of that judgment. The experiencing self had whole hours of pleasure and just a moment of displeasure, but the remembering self sees no pleasure at all...Why would a football fan let a few flubbed minutes at the end of the game ruin three hours of bliss? Because a football game is a story. And in stories, endings matter.
  16. No one ever really has control. Physics and biology and accident ultimately have their way in our lives. But the point is that we are not helpless either. Courage is the strength to recognize both realities. We have room to act, to shape our stories, though as time goes on it is within narrower and narrower confines.
  17. Assisted living is far harder than assisted death, but its possibilities are far greater, as well.