Being Mortal : Atul Gawande 

Medicine and What Matters in the End

A guide of death and what happens before.

There is emergence of literature which is discussing the prior death experiences which was not much talked about previously. Paul Kalanithi's "When breath becomes Air" was recommended to me by an oncologist but haven't followed that genre for long. 

I picked up Being Mortal : Atul Gawande published by Penguin Books recently and this was my first book of Dr. Gawande's literature who has mostly written on medicine and its interaction with humans. The book talks about the need to talk about detah and how medical profession is failing to keep up with the idea of dignified death and harps upon artficial life elongation instead of focussing on quality of life. The author banks upon his own experiences as a physician based in USA and near experiences of his father who himself was a doctor and develops cancer after 7 decades of healthy life . He states that the textbooks had noting on aging, fraility or dying and there is no discussion on how process unfolds, how people experience the end of their lives and how it affects those around them. He adds that the prupose of medical schooling was to teach  how to save lives, not how to tend to their demise. He shares startling fact that as recently as 1945, most of the deaths occured at homes and by 1980s only 17 percent of the death occured at home.

The book consists of 8 chapters on same theme but different aspects of a medical professionls tackling near death experiences. 

The book mentions how in India the death and old age was a community experience instead of persons individual or family matter. "In contemporary societies, by contrast, old age and infirmity have gone from being shared, multigenerational responsibility to a more or less private state - Something experienced largely alone or with the aid of doctors and institutions. How did this happen?" ... "One answer is that old age itself has changed. In the past, surviving to old age was uncommon, and those who did survive served special purpose as guardians of tradition, knowledge and history. They tended to maintain their status and authority as heads of the household until death. Further he adds, "People have always lied about how old they are. Demographers call the phenomena, age keeping and have devised complex quantitative contortions to correct for all the lying in the senses."

He adds that the modernisation did not demote the elderly. It demoted the family. The veneration of elderly has been replaced by the veneration of the independent self. The author describes that there is no sudden advent of process leading to death but "No single common cellular mechanism to the ageing process. Our bodies accumulate Lippo fusion and oxygen-free radicals damage and random DNA mutations and numerous other microcell problems. The process is gradual and unrelenting."Further he adds that "old is not a diagnosis. There is always some final proximate cause that gets written down on the death certificate: respiratory failure, cardiac arrest, but in the truth, no single disease leads to the end. The culprit is just the accumulated crumbling of one’s bodily systems while medicine carries out its maintenance measures and paid jobs." 

The author discusses type of medical professionals in the chapter Hard Conversations. He feels that most of the time all doctors have paternalistic relationships and they feel that doctors know what is best for the patients. The second type of relationship the doctors term is informative, where doctor is a technical expert, the patient is the consumer and the doctor provides the data and support to the patient. Who takes his final decision. The third type of doctor patient-relationship is called interpretive. Where Doctors role is to help patient determine what they want. What is most important to them? What are their worries and it is called shared decision-making. 

Deriving the Daniel Kahneman's famous Peak End Rule from his book Thinking Fast and Slow, he mentions that "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. a seemingly happy life maybe empty, a seemingly difficult life maybe devoted to greater cause. we have purposes larger than our self."

Overall it is a very engrossing book, must read for everyone. He has presented first hand narrative of death experiences of his patients and his father. The comparison between India and West is quite realistic and it also tells why in India old age is still not a curse unlike USA where fierce individualistic life decisions and societal values has eroded that concept of family and at the fag end of their life people are left to fend for themselves. It also gives us an alert that india with its huge demography has to plan for old age in coming future because of the bulgeoning graph.

Do read and share feedback,