Medical Problems Or The Meaning of Life?

This is Dr. Phillip Periman. I am a retired hematologist/oncologist in Amarillo, Texas. I have been asked to review Dr. Atul Gawande’s  Being Mortal: Medicine and What Matters in the End published in 2014 and now available in paperback. 
 
 
Two chapters, “Things Fall Apart” and “Letting Go,” first appeared as articles in The New Yorker for which Gawande regularly writes. He is a surgeon in the Harvard system in Boston. I try to read everything he writes, as his thinking and writing about medicine, in my opinion, is the best currently available.
 
 
 
Being Mortal is his fourth book and is considered by many to be his best, perhaps because it is so personal. Two aging and dying family members inspired this book. The deterioration of his wife’s grandmother, Alice Hopson, caused Gawande to examine the role of nursing homes and assisted living facilities in our society. A diagnosis of a rare cancer, astrocytoma of the spinal cord, in his father forced Gawande to learn about palliative care, hospice, and the end of life.
 
One of Gawande’s first contentions is that we as a people are not comfortable confronting or thinking about the inevitability of our aging and dying. He contends this avoidance leads our society to expensive and harmful care of the elderly. He is particularly concerned that we have made aging a medical problem and not a meaningful life issue. His take on medical education is that medical students and young physicians learn how to diagnosis and treat, but not how to think about the elderly. The first sentence in the book, “I learned about a lot of things in medical school, but mortality wasn’t one of them,” sets up his position.
 
 
 
His first personal observation about learning about mortality was the weekly medical seminar called Patient-Doctor in which they discussed the suffering of Ivan Ilyich as he lay ill and worsening from some unnamed, untreatable disease in Tolstoy’s “The Death of Ivan Ilyich.”  I confess to never having read the novella, but I concur that my medical education was short in death and dying. We had one lecture in my senior year on how to deal with a patient dying of Hodgkin’s disease. This was before we had learned that chemotherapy could cure advanced Hodgkin’s lymphoma.
 
 
 
Two years later in 1967 when I was a first-year resident I cared for two patients under the age of forty who were dying of malignancies. In preparing for a presentation to the chief of medicine about these two patients, I read everything that was available in the library. I found less than a half a dozen books and articles.
 
 
 
Kubler-Ross’s landmark book On Death and Dying was not published until 1969. Gawande documents how even as medical care has advanced, the teaching of how to care for our increasingly aging population has not kept up. He writes, “When I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality, and it did not take long to realize how unready I was to help them.” Gawande tells the story of a patient with incurable cancer whose decision to receive aggressive care did not accomplish much. In the end, Gawande had to remove the patient from artificial ventilation.
 
In retrospect, Gawande noted, “We all avoided talking honestly about the choice before him”(the patient) and how “we never really touched on the reality of his disease.” Gawande reminds us that “death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.” His book is about the modern experience of mortality “and where our ideas about how to deal with our finitude have got the reality wrong.”
 
 
 
In the next three essays, I will explore his ideas about nursing homes, assisted living, and hospice.