Being Mortal: Medicine and What Matters in the End

by Gawande, Atul

  Yet I was still intensely moved and grateful to have gotten to do my part. For one, my father had wanted it, and my mother and sister did, too. Moreover, although I didn’t feel my dad was anywhere in that cup and a half of gray, powdery ash, I felt that we’d connected him to something far bigger than ourselves, in this place where people had been performing these rituals for so long.

  When I was a child, the lessons my father taught me had been about perseverance: never to accept limitations that stood in my way. As an adult watching him in his final years, I also saw how to come to terms with limits that couldn’t simply be wished away. When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that there are times when the cost of pushing exceeds its value. Helping my father through the struggle to define that moment was simultaneously among the most painful and most privileged experiences of my life.

  Part of the way my father handled the limits he faced was by looking at them without illusion. Though his circumstances sometimes got him down, he never pretended they were better than they were. He always understood that life is short and one’s place in the world is small. But he also saw himself as a link in a chain of history. Floating on that swollen river, I could not help sensing the hands of the many generations connected across time. In bringing us there, my father had helped us see that he was part of a story going back thousands of years—and so were we.

  We were lucky to get to hear him tell us his wishes and say his good-byes. In having a chance to do so, he let us know he was at peace. That let us be at peace, too.

  After spreading my father’s ashes, we floated silently for a while, letting the current take us. As the sun burned away the mist, it began warming our bones. Then we gave a signal to the boatman, and he picked up his oars. We headed back toward the shore.

  Notes on Sources

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  INTRODUCTION

  Tolstoy’s classic novella: Leo Tolstoy, The Death of Ivan Ilyich, 1886 (Signet Classic, 1994).

  I began writing: A. Gawande, Complications (Metropolitan Books, 2002).

  As recently as 1945: National Office of Vital Statistics, Vital Statistics of the United States, 1945 (Government Printing Office, 1947), p. 104, http://www.cdc.gov/nchs/data/vsus/vsus_1945_1.pdf.

  In the 1980s: J. Flory et al., “Place of Death: U.S. Trends since 1980,” Health Affairs 23 (2004): 194–200, http://content.healthaffairs.org/content/23/3/194.full.html.

  Across not just the United States: A. Kellehear, A Social History of Dying (Cambridge University Press, 2007).

  The late surgeon Sherwin Nuland: S. Nuland, How We Die: Reflections on Life’s Final Chapter (Knopf, 1993).

  1: THE INDEPENDENT SELF

  Even when the nuclear family: P. Thane, ed., A History of Old Age (John Paul Getty Museum Press, 2005).

  one child usually remained: D. H. Fischer, Growing Old in America: The Bland-Lee Lectures Delivered at Clark University (Oxford University Press, 1978). Also C. Haber and B. Gratton, Old Age and the Search for Security: An American Social History (Indiana University Press, 1994).

  the poet Emily Dickinson: C. A. Kirk, Emily Dickinson: A Biography (Greenwood Press, 2004).

  surviving into old age was uncommon: R. Posner, Aging and Old Age (University of Chicago Press, 1995), see ch. 9.

  They tended to maintain their status … Whereas today people often understate: Fischer, Growing Old in America.

  In America, in 1790: A. Achenbaum, Old Age in the New Land (Johns Hopkins University Press, 1979).

  today, they are 14 percent: United States Census Bureau, http://quickfacts.census.gov/qfd/states/00000.html.

  In Germany, Italy, and Japan: World Bank, http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS.

  100 million elderly: “China’s Demographic Time Bomb,” Time, Aug. 31, 2011, http://www.time.com/time/world/article/0,8599,2091308,00.html.

  As for the exclusive hold: Posner, ch. 9.

  increased longevity has brought: Haber and Gratton, pp. 24–25, 39.

  Historians find that the elderly … The radical concept of “retirement”: Haber and Gratton.

  Life expectancy: E. Arias, “United States Life Tables,” National Vital Statistics Reports 62 (2014): 51.

  Family sizes fell: L. E. Jones and M. Tertilt, “An Economic History of Fertility in the U.S., 1826–1960,” NBER Working Paper Series, Working Paper 12796, 2006, http://www.nber.org/papers/w12796.

  The average age at which: Fischer, appendix, table 6.

  “intimacy at a distance”: L. Rosenmayr and E. Kockeis, “Propositions for a Sociological Theory of Aging and the Family,” International Social Science Journal 15 (1963): 410–24.

  Whereas in early-twentieth-century America: Haber and Gratton, p. 44.

  The pattern is a worldwide one: E. Klinenberg, Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone (Penguin, 2012).

  Just 10 percent: European Commission, i2010: Independent Living for the Ageing Society, http://ec.europa.eu/information_society/activities/ict_psp/documents/independent_living.pdf.

  Del Webb: J. A. Trolander, From Sun Cities to the Villages (University Press of Florida, 2011).

  2: THINGS FALL APART

  trajectory of our lives: J. R. Lunney et al., “Patterns of Functional Decline at the End of Life,” Journal of the American Medical Association 289 (2003): 2387–92. The graphs in this chapter are adapted from the article.

  By the middle of the twentieth century: National Center for Health Statistics, Health, United States, 2012: With Special Feature on Emergency Care (Washington, DC: U.S. Government Printing Office, 2013).

  People with incurable cancers … The curve of life becomes a long slow fade: J. R. Lunney, J. Lynn, and C. Hogan, “Profiles of Older Medicare Decedents,” Journal of the American Geriatrics Society 50 (2002): 1109. See also Lunney et al., “Patterns of Functional Decline.”

  Consider the teeth: G. Gibson and L. C. Niessen, “Aging and the Oral Cavity,” in Geriatric Medicine: An Evidence-Based Approach, ed. C. K. Cassel (Springer, 2003), pp. 901–19. See also I. Barnes and A. Walls, “Aging of the Mouth and Teeth,” Gerodontology (John Wright, 1994).

  the muscles of the jaw lose: J. R. Drummond, J. P. Newton, and R. Yemm, Color Atlas and Text of Dental Care of the Elderly (Mosby-Wolfe, 1995), pp. 49–50.

  By the age of sixty: J. J. Warren et al., “Tooth Loss in the Very Old: 13-15-Year Incidence among Elderly Iowans,” Community Dentistry and Oral Epidemiology 30 (2002): 29–37.

  Under a microscope: A. Hak et al., “Progression of Aortic Calcification Is Associated with Metacarpal Bone Loss during Menopause: A Population-Based Longitudinal Study,” Arteriosclerosis, Thrombosis, and Vascular Biology 20 (2000): 1926–31.

  Research has found that loss of bone density: H. Yoon et al., “Calcium Begets Calcium: Progression of Coronary Artery Calcification in Asymptomatic Subjects,” Radiology 224 (2002): 236–41; Hak et al., “Progression of Aortic Calcification.”

  more than half of us: N. K. Wenger, “Cardiovascular Disease,” in Geriatric Medicine, ed. Cassel (Springer, 2003); B. Lernfeit et al., “Aging and Left Ventricular Function in Elderly Healthy People,” American Journal of Cardiology 68 (1991): 547–49.

  muscle elsewhere thins: J. D. Walston, “Sarcopenia in Older Adults,” Current Opinion in Rheumatology 24 (2012): 623–27; E. J. Metter et al., “Age-Associated Loss of Power and Strength in the Upper Extremities in Women and Men,” Journal of Gerontology: Biological Sciences 52A (1997): B270.

  You can see all these processes: E. Carmeli, “The Aging Hand,” Journal of Gerontology: Medical Sciences 58A (2003): 146–52.

  This is normal: R. Arking, The Biolog
y of Aging: Observations and Principles, 3rd ed. (Oxford University Press, 2006); A. S. Dekaban, “Changes in Brain Weights During the Span of Human Life: Relation of Brain Weights to Body Heights and Body Weights,” Annals of Neurology 4 (1978): 355; R. Peters, “Ageing and the Brain,” Postgraduate Medical Journal 82 (2006): 84–85; G. I. M. Craik and E. Bialystok, “Cognition Through the Lifespan: Mechanisms of Change,” Trends in Cognitive Sciences 10 (2006): 132; R. S. N. Liu et al., “A Longitudinal Study of Brain Morphometrics Using Quantitative Magentic Resonance Imaging and Difference Image Analysis,” NeuroImage 20 (2003): 26; T. A. Salthouse, “Aging and Measures of Processing Speed,” Biological Psychology 54 (2000): 37; D. A. Evans et al., “Prevalence of Alzheimer’s Disease in a Community Population of Older Persons,” JAMA 262 (1989): 2251.

  Why we age: R. E. Ricklefs, “Evolutionary Theories of Aging: Confirmation of a Fundamental Prediction, with Implications for the Genetic Basis and Evolution of Life Span,” American Naturalist 152 (1998): 24–44; R. M. Zammuto, “Life Histories of Birds: Clutch Size, Longevity, and Body Mass among North American Game Birds,” Canadian Journal of Zoology 64 (1986): 2739–49.

  The idea that living things shut down: C. Mobbs, “Molecular and Biologic Factors in Aging,” in Geriatric Medicine, ed. Cassel; L. A. Gavrilov and N. S. Gavrilova, “Evolutionary Theories of Aging and Longevity,” Scientific World Journal 2 (2002): 346.

  average life span of human beings: S. J. Olshansky, “The Demography of Aging,” in Geriatric Medicine, ed. Cassel; Kellehear, A Social History.

  As Montaigne wrote: Michel de Montaigne. The Essays, sel. and ed. Adolphe Cohn (G. P. Putnam’s Sons, 1907), p. 278.

  inheritance has surprisingly little influence: G. Kolata, “Live Long? Die Young? Answer Isn’t Just in Genes,” New York Times, Aug. 31, 2006; K. Christensen and A. M. Herskind, “Genetic Factors Associated with Individual Life Duration: Heritability,” in J. M. Robine et al., eds., Human Longevity, Individual Life Duration, and the Growth of the Oldest-Old Population (Springer, 2007).

  If our genes explain less: Gavrilov and Gavrilova, “Evolutionary Theories of Aging and Longevity.”

  Hair grows gray: A. K. Freeman and M. Gordon, “Dermatologic Diseases and Problems,” in Geriatric Medicine, ed. Cassel, 869.

  Inside skin cells: A. Terman and U. T. Brunk, “Lipofuscin,” International Journal of Biochemistry and Cell Biology 36 (2004): 1400–4; Freeman and Gordon, “Dermatologic Diseases and Problems.”

  The eyes go: R. A. Weale, “Age and the Transmittance of the Human Crystalline Lens,” Journal of Physiology 395 (1988): 577–87.

  the “rectangularization” of survival: Olshansky, “The Demography of Aging.” See also US Census Bureau data for 1950, http://www.census.gov/ipc/www/idbpyr.html. Additional data from Population Pyramid online, http://populationpyramid.net/.

  We cling to the notion of retirement: M. E. Pollack, “Intelligent Technology for an Aging Population: The Use of AI to Assist Elders with Cognitive Impairment,” AI Magazine (Summer 2005): 9–25. See also Federal Deposit Insurance Corporation, Economic Conditions and Emerging Risks in Banking: A Report to the FDIC Board of Directors, May 9, 2006, http://www.fdic.gov/deposit/insurance/risk/2006_02/Economic_2006_02.html.

  Equally worrying: Data on certifications in geriatrics from American Board of Medical Specialties and American Board of Internal Medicine.

  350,000 Americans fall and break a hip: M. Gillick, The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies (Harvard University Press, 2006).

  Several years ago, researchers at the University of Minnesota: C. Boult et al., “A Randomized Clinical Trial of Outpatient Geriatric Evaluation and Management,” Journal of the American Geriatrics Society 49 (2001): 351–59.

  In a year, fewer than three hundred doctors: American Board of Medical Specialties, American Board of Psychiatry and Neurology; L. E. Garcez-Leme et al., “Geriatrics in Brazil: A Big Country with Big Opportunities,” Journal of the American Geriatrics Society 53 (2005): 2018–22; C. L. Dotchin et al., “Geriatric Medicine: Services and Training in Africa,” Age and Ageing 41 (2013): 124–28.

  The risk of a fatal car crash: D. C. Grabowski, C. M. Campbell, and M. A. Morrissey, “Elderly Licensure Laws and Motor Vehicle Fatalities,” JAMA 291 (2004): 2840–46.

  in Los Angeles, George Weller: J. Spano, “Jury Told Weller Must Pay for Killing 10,” Los Angeles Times, Oct. 6, 2006, http://articles.latimes.com/2006/oct/06/local/me-weller6.

  3: DEPENDENCE

  In 1913, Mabel Nassau: M. L. Nassau, Old Age Poverty in Greenwich Village: A Neighborhood Study (Fleming H. Revell Co., 1915).

  Unless family could take such people in: M. Katz, In the Shadow of the Poorhouse (Basic Books, 1986); M. Holstein and T. R. Cole, “The Evolution of Long-Term Care in America,” in The Future of Long-Term Care, ed. R. H. Binstock, L. E. Cluff, and O. Von Mering (Johns Hopkins University Press, 1996).

  A 1912 report: Illinois State Charities Commission, Second Annual Report of the State Charities Commission, 1912, pp. 457–508; Virginia State Board of Charities and Corrections, First Annual Report of State Board of Charities and Corrections, 1909.

  Nothing provoked greater terror: Haber and Gratton, Old Age and the Search for Security.

  the case of Harry Truman: M. Barber, “Crotchety Harry Truman Remains an Icon of the Eruption,” Seattle Post-Intelligencer, March 11, 2000; S. Rosen, Truman of Mt. St. Helens: The Man and His Mountain (Madrona Publishers, 1981). Two bands have put out songs inspired by Truman: R. W. Stone’s 1980 country rock hit, “Harry Truman, Your Spirit Still Lives On,” http://www.youtube.com/watch?v=WGwa3N43GB4, and Headgear’s 2007 indie rock single, “Harry Truman,” http://www.youtube.com/watch?v=JvcZnKkM_DE.

  In the middle part of the twentieth century: L. Thomas, The Youngest Science (Viking, 1983).

  Congress passed the Hill-Burton Act: A. P. Chung, M. Gaynor, and S. Richards-Shubik, “Subsidies and Structure: The Last Impact of the Hill-Burton Program on the Hospital Industry,” National Bureau of Economics Research Program on Health Economics meeting paper, April 2013, http://www.nber.org/confer/2013/HEs13/summary.htm.

  Meanwhile, policy planners: A key source for the history of nursing homes was B. Vladeck, Unloving Care: The Nursing Home Tragedy (Basic Books, 1980). See also Holstein and Cole, “Evolution of Long-Term Care,” and records from the City of Boston and its almshouse: https://www.cityofboston.gov/Images_Documents/Guide%20to%20the%20Almshouse%20records_tcm3-30021.pdf.

  As one scholar put it: Vladeck, Unloving Care.

  The sociologist Erving Goffman: E. Goffman Asylums (Anchor, 1961). Corroborated by C. W. Lidz, L. Fischer, and R. M. Arnold, The Erosion of Autonomy in Long-Term Care (Oxford University Press, 1992).

  4: ASSISTANCE

  Your chances of avoiding the nursing home: G. Spitze and J. Logan, “Sons, Daughters, and Intergenerational Social Support,” Journal of Marriage and Family 52 (1990): 420–30.

  “Her vision was simple”: K. B. Wilson, “Historical Evolution of Assisted Living in the United States, 1979 to the Present,” Gerontologist 47, special issue 3 (2007): 8–22.

  In 1988, the findings were made public: K. B. Wilson, R. C. Ladd, and M. Saslow, “Community Based Care in an Institution: New Approaches and Definitions of Long Term Care” paper presented at the 41st Annual Scientific Meeting of the Gerontological Society of America, San Francisco, Nov. 1988. Cited in Wilson, “Historical Evolution.”

  In 1943, the psychologist Abraham Maslow: A. H. Maslow, “A Theory of Human Motivation,” Psychological Review 50 (1943): 370–96.

  Studies find that as people grow older: D. Field and M. Minkler, “Continuity and Change in Social Support between Young-Old, Old-Old, and Very-Old adults,” Journal of Gerontology 43 (1988): 100–6; K. Fingerman and M. Perlmutter, “Future Time Perspective and Life Events across Adulthood,” Journal of General Psychology 122 (1995): 95–111.

  In one of her most influential studies: L. L. Carstensen et al., “Emotio
nal Experience Improves with Age: Evidence Based on over 10 Years of Experience Sampling,” Psychology and Aging 26 (2011): 21–33.

  She produced a series of experiments: L. L. Carstensen and B. L. Fredrickson, “Influence of HIV Status on Cognitive Representation of Others,” Health Psychology 17 (1998): 494–503; H. H. Fung, L. L. Carstensen, and A. Lutz, “Influence of Time on Social Preferences: Implications for Life-Span Development,” Psychology and Aging 14 (1999): 595; B. L. Fredrickson and L. L. Carstensen, “Choosing Social Partners: How Old Age and Anticipated Endings Make People More Selective,” Psychology and Aging 5 (1990): 335; H. H. Fung and L. L. Carstensen, “Goals Change When Life’s Fragility Is Primed: Lessons Learned from Older Adults, the September 11 Attacks, and SARS,” Social Cognition 24 (2006): 248–78.

  By 2010, the number of people in assisted living: Center for Medicare and Medicaid Services, Nursing Home Data Compendium, 2012 Edition (Government Printing Office, 2012).

  A survey of fifteen hundred assisted living facilities: C. Hawes et al., “A National Survey of Assisted Living Facilities,” Gerontologist 43 (2003): 875–82.

  5: A BETTER LIFE

  In a book he wrote: W. Thomas, A Life Worth Living (Vanderwyk and Burnham, 1996).

  And other research was consistent: J. Rodin and E. Langer, “Long-Term Effects of a Control-Relevant Intervention with the Institutionalized Aged,” Journal of Personality and Social Psychology 35 (1977): 897–902.