Being Mortal

Atul Gawande once again uses his skill to beautifully explain and improve the world around us. This time it isn’t checklists, it’s about the process of the end of our lives. He combines stories of his family and patients, together with sweeping insights and critiques of our current medical system. Here are my thoughts:

People who age want to age well, not only keep their health. But the latter is what our systems are built for, and although that is good, it forgets that older people are … well … people. And they want to be treated that way, not only as a body that needs to be kept alive. So talk about living, not focus only on dying.
Stories of defiance and staying in control of their journey (and story) is what resonates with many older people. This should give us pause and consider what would be best for them (and us later on). Maybe that is not keeping us alive with tubes to the end. Maybe that is living a good life until the end.
This also means that less medicine may be a better solution for many. More medicine, in most cases, doesn’t correlate with more healthy days/years.
And discussing death (or end of life) is one of the best ways to improve that time on earth. In other words, when talking seriously about this, you can’t (always, but sometimes) expect to live longer, but the last years will be happier and more meaningful.
For doctors, the incentives are also sometimes wrong. They get paid for doing surgery, not for talking with patients. I hope that with the coming age of AI, we will make more time and room for these talks as machines take over more and more of the cutting work.

There is a tension between autonomy and safety. As children of ageing parents, you want safety (like you would want for your child), but (like your children) your parents want autonomy. We’re asking ourselves ‘Is this a place where I would leave mom and feel good about it? (safety)’ instead of ‘Is this a place where mom would be happy? (autonomy)’. This reminds me of the book Drive, where the three motivations of humans are laid out: autonomy, mastery, purpose.
The need for safety comes from a good place. It’s love and dedication. But that is just what can get in the way of letting someone live a life worth living (even if that is a bit more dangerous).
People want/need a purpose to live. Gawande also calls this loyalty or transcendence (also coined as an extra layer on top of Maslov’s pyramid). It’s caring for something bigger than yourself, for the future, for others.
One way this is encouraged is with animals and plants. In a few different experiments, time and time again they show that bringing in animals has a positive effect on the lives of the elderly residents. It also lowers medicine use (by more than half) and anecdotal evidence even indicated that it helped people go back to unassisted living.

Another interesting point in the book is the behaviour of doctors. Gawande speaks of their optimism and hope they provide for their patients. But in many cases, this is just a way to not have the hard conversations. It’s recommending that people do another experimental treatment that will only cause extra suffering for that 1% chance that it prolongs their life.
This problem is even worse with patients they know better. The doctors are misleading themselves and their patients. Discussing a fantasy is easier than having the hard conversation. Gawande argues that we should all have those hard conversations, probably earlier than we want!

Being mortal takes courage. Courage on two levels. It’s about getting the knowledge, confronting yourself with the facts. And to act on that knowledge.
That is the power of hard conversations.

We evaluate our experiences on two levels. One level is the experiencing self. The other level is the remembering self.
The second ones only remembers the peak and the end (the peak-end rule).
The way we remember is therefore vastly different from the way we experience life.
This ties in to the great book, Thinking: Fast and Slow by Daniel Kahneman.

“In the end, people don’t view their life as merely the average of all its moments—which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people’s minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.”

“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 recognize 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.”

Video review: https://www.youtube.com/watch?v=3tWagD0cOIY

New York Time review: https://www.nytimes.com/2014/11/09/books/review/atul-gawande-being-mortal-review.html