walkitout (walkitout) wrote,

_Being Mortal_, Atul Gawande

A book group selection for the library reading group in Mayberry, NH (<-- not its real name).

The back of the book has some very favorable reviews on the back. Some of them seem a little over the top, but basically accurate. "This is Atul Gawande's most powerful -- and moving -- book." Others, not so much. "it is an essential and insightful book for our times", for example.

Here's what I thought.

Like Gawande's writing in general, it is compulsively readable. If you can start, he'll provide the motivation to continue. Afterwards, you may or may not wish you had spent the time reading the book -- but you will likely finish.

Like surgeons in general, Gawande suffers from too much of an uninspected fix-it mentality. Sure, he's talking about how we don't handle end of life well, but even when he's telling you how great hospice care is and how he completely failed to understand it prior to looking into it for writing this book, he wildly underappreciates what hospice is and why it really ought to be our model for all care, not just end of life. (Seriously. Why _wouldn't_ you ask, will this treatment give me more, better time alive versus no treatment, or an alternative, quality of life oriented form of treatment. Yeah -- why _is it_ that we don't start there?)

A few years back (2008), when a person in my extended family was visiting various assisted/active/retirement facilities, it occurred to me that I didn't really know anything about any of this. In classic Walkitout Style, I promptly found three books on the general topic and read them. ALL of those book were better than Gawande's _Being Mortal_, individually and collectively. The only thing _Being Mortal_ has going for it is that it was written enough later than the other three that it has a little more information on how things like Eden Alternative, Green Houses, Beacon Street Village etc. have progressed (he doesn't ever mention The Mount, which is another irritation -- it's like the west coast doesn't exist in this book). Oh, and I think Gawande's history of the rise of assisted living is a little stronger, and he has some really great quotes from other people on how to conduct conversations about end of life care. But that's it. Everything else is substantially weaker than the other three books.

_Old Age in a New Age: The Promise of Transformative Nursing Homes_ by Beth Baker
_Nobody's Home: Candid Reflections of a Nursing Home Aide_, Thomas Edward Gass
_No Place Like Home: A History of Nursing and Home Care in the United States_, by Karen Buhler-Wilkerson

I'm fully prepared to believe that there are other books of intermediate or even more recent vintage, which cover this and related topics and are also excellent. Should you know of any, don't hesitate to email me or tell me about them in the comments.

Like a lot of surgeons who have watched beloved family members die, Gawande is disgustingly insensitive on the topic of death with dignity. "But the fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success. It is a measure of failure. Our ultimate goal, after all, is not a good death but a good life to the very end."

Dude, that might be your goal, but realizing it is not everyone else's goal is sort of what you were supposed to be learning while writing this book and obviously, you didn't. A good life to the not-quite-bitter-end would seem to me -- and, apparently, a lot of Dutch people -- preferable to deciding that, say, being able to watch football on TV and eat chocolate ice cream is worth a few more days of being alive, for suitable definitions of alive (that involve a lot of tubes, vents, quadripeligia and a complex pharma routine designed to tamp the pain down to a manageable level while still keeping you awake -- sounds just dandy to me). What data there is on Dutch people trying to access death with dignity suggest that patients are having to override physicians and other health care professionals who think there are more palliative care options left to try. Having read Gawande's idea of what's worth trying and what isn't -- and reading his description of his father's opinions when it mattered the most vs. his mother's -- it seems clear to me that Gawande continues to suffer not only from fix it mentality, but also the delusions of the healthy: that another few hours or even days of awfulness are somehow Worth It, to someone (it always sounds like that someone is the healthier family, not the dying member).

All that said, readability and up-to-dateness count for a lot. If you realize you are unaware of the state of end of life options (where to live and how to manage the medicalization of end of life care), this is a _great_ choice. Thinking about these things is better than NOT thinking about these things. Whatever conclusions you come to (or don't) are obviously going to be your own and they will almost certainly differ from mine, my sister's, and everyone else I know. To the extent this book helps people engage in that thinking and related conversations with loved ones, it's a good book.
Tags: book review
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