Being Mortal

by

Atul Gawande

Being Mortal: Chapter 2 Summary & Analysis

Summary
Analysis
For most of history, death was a common, ever-present possibility. For most people, life would continue nicely until illness hit and people would deteriorate quickly—like Gawande’s grandmother Gopikabai Gawande, who died of malaria before she was 30. But now, public health measures and advances in science have reduced the mortality of infection, traumatic injuries, childbirth, heart attacks, strokes, and many other conditions.
One of the primary ways that medicine and public health have changed the way we live and die is by remedying many illnesses and injuries that once were fatal. Because of this, death is no longer a “common, ever-present danger,” it is one that we don’t have to consider for most of our lives.
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Even people with incurable cancers can undergo treatment, bringing symptoms under control for much longer. Although people still deteriorate rapidly, the point at which the bottom drops out occurs much later. Even if doctors can’t stave off damage, they can stave off death. When people enter hospitals looking terrible, doctors can provide them with care that allows them to recover some ground. On the whole, however, medical progress has allowed large numbers of people to get a full life span and die essentially of old age, as people’s bodily systems fail over time.
This passage emphasizes how amazing medical advancement has become, and how it has allowed even people with illness to live much fuller, healthier lives. But it also raises the issue that now it is much more difficult to know when someone with a terminal illness may die, leading people to cling to hope that they may live much longer than they actually will.
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While medicine and public health have allowed for great progress, they have changed the way we think about old age. When people need help, they see this as weakness rather than a normal state of affairs. While one 97-year-old may be able to run a marathon, this is not the norm, and it is unrealistic to believe in this fantasy. This progress also makes it difficult for doctors to know how to treat people in old age unless there is a discrete problem to fix.
Because of medicine, people often maintain false hopes about what their own end of life might look like. They look at fit 97-year-olds rather than confronting the much more likely scenarios of disability and illness. And doctors are just as guilty about avoiding the reality of death as average people are.
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Quotes
Teeth are a good example of the natural way in which people age. While dental care can help avert tooth loss, old age gets in the way: the gums become enflamed, the roots of the teeth atrophy, and problems like arthritis make it difficult to brush and floss. The ability to chew food declines, and people shift to soft food, which are higher in carbs and more likely to cause cavities. By 85, almost 40 percent of people have no teeth.
Here the book provides some examples of the different ways in which people age to show how aging is both a natural and inevitable process. Acknowledging that it can’t be stopped is a crucial part of helping people face mortality, even though they don’t want to think about these issues. Even though people can take care of their teeth and body, doing so cannot prevent this decay.
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While bones and teeth soften, the rest of the body hardens. Blood vessels, joints, and muscles pick up calcium deposits as bones wear away, and they stiffen. To maintain the same volume of blood flow through these blood vessels, the heart generates increased pressure, and more than half of people develop hypertension by 65. The heart muscle thickens, and muscle elsewhere thins and deteriorates.
Gawande then provides even more examples of how the body breaks down on a large scale. These aren’t appealing prospects, but it is important to acknowledge them as a part of ultimately confronting mortality.
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All of these processes are normal. While they can be slowed, they cannot be stopped. Lung capacity decreases, bowels slow, brains shrink—losing particularly the areas devoted to memory, judgment, and planning. Why we age is a subject of debate: the classical view is that aging happens because of wear and tear, but the newest view suggests that aging is genetically programmed, which is why most people prior to the past few hundred years died before 30. Thus, aging today is a very unnatural process.
Aging is so natural that it is even genetically programmed into us. So while death may seem like a “failure,” as Gawande noted before, it is just as inherent in our DNA as our other traits. This passage also emphasizes how it is medical progress, not our natural bodies, that has enabled people to live as long as they do.
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Nonetheless, genetic inheritance has little influence on longevity, and so wear and tear may explain more than expected. Leonid Gavrilov, a researcher at the University of Chicago, argues that human beings fail the way complex systems fail: randomly and gradually. Humans are designed with many backup systems and redundancies, allowing us to function even as damage accumulates. But as defects increase, there is a point in time where one more defect is enough to impair the whole system.
This further peek into how we die becomes another way to destigmatize death and explore what causes it. It shows how ultimately, death just comes as an accumulation of defects. This also makes it difficult for doctors to know how to treat aging, because there is no one cause specifically; aging consists instead of many issues that build up.
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People choose to avoid the subject of aging and death, and as a result, few societies have come to terms with the increasing number of old people. While the retirement age is still 65, people over this age approach close to 20 percent of the population, and few people give thought to how they will live in these later years. Additionally, these days people are putting aside less in savings for old age than they have at any time since the Great Depression.
This passage touches on why avoiding the topics of death and aging are problematic. More and more people are reaching old age, but without giving any thought as to how they want to live during this period. Part of Gawande’s intention in writing the book is to remedy this fact.
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At the same time, there is a shortage of geriatricians in the medical profession, because it pays less compared to other jobs in medicine. Additionally, many people dislike taking care of the elderly, who often have a multitude of problems and can be difficult to treat. There’s nothing glamorous about taking care of high blood pressure, diabetes, or arthritis. One cannot cure these things—but one can manage them.
Even though medicine has enabled people to live longer, the field hasn’t adapted to these changing demographics. The lack of geriatricians necessitates some reform in this area, as Gawande explores later in the chapter.
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Quotes
One morning, Gawande sits in on some patient visits in the geriatric clinic in his hospital with the chief geriatrician, Juergen Bludau. The doctor’s first patient, an 85-year-old woman named Jean Gavrilles, has lower back and leg pain. She also has bad arthritis, high blood pressure, and glaucoma. Lately, she’s had trouble controlling her bowels, and she recently had surgery for colon cancer. Gavrilles lives alone, and she takes care of herself capably.
Sitting in on the geriatrics appointments, Gawande recognizes the vast array of problems that can befall someone in old age, and he identifies which conditions they can live with. This is what makes geriatricians so key, as they navigate all of these different conditions to figure out how to best improve someone’s life.
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Bludau asks about Jean’s day in great detail before examining her. She is in good condition for her age, but she faces everything from arthritis and incontinence to what might be metastatic colon cancer. Gawande thinks that the doctor could focus on the most potentially life threatening problem (the cancer) or the problem that bothers Jean the most (the back pain). But instead, the doctor spends most of the time looking at her feet, because often older people cannot bend down to reach their feet, and this suggests real danger and neglect.
Gawande acknowledges that Bludau’s training as a geriatrician specifically gives him insight that Gawande, even for all his experience, doesn’t have. The aging population has made geriatricians extremely vital, because only these doctors have this specialized training, and as the population grows steadily older due to advances in medicine and technology, geriatricians prove more and more critical.
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Bludau informs Jean that she’s doing impressively well, and the most serious threat she faces is falling. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people with all three have almost a 100 percent chance of falling in a given year, and Jean has at least two. She has poor balance, as indicated by her neglected feet. And she’s on five medications, some of which have the side effect of dizziness. But she doesn’t have muscle weakness, and Bludau wants her to preserve her strength.
While Gawande focuses on Jean’s discrete ailments, Bludau knows instead to focus on her overall condition. This is what makes the geriatricians so important, as Gawande highlights how, by contrast, regular doctors overly focus on certain ailments at the expense of well-being.
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Later, Bludau tells Gawande that his job is to support quality of life: both freedom from disease, and the retention of enough function for active engagement in the world. He switches some of Jean’s medications to avoid dizziness, recommends a podiatrist for her feet, and also suggests that she eat a snack during the day to keep her muscles strong. Almost a year later, Gawande follows up with Jean: she is eating better and still lives comfortably, without a single fall.
Bludau’s recommendations, and Jean’s condition a year later, illustrate the importance of focusing on well-being. Even though Jean has some concerning conditions, Bludau is able to keep them in check enough so that she doesn’t have a larger health problem—a fall—and can continue to live in the way that she wishes.
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Quotes
When Alice Hobson began to fall frequently, Gawande didn’t understand how much of an alarm bell that was. She then got into a car accident, mistaking the brake for the accelerator. Soon after, two men scammed her out of $7,000 when they did yard work for her and cornered her in her house until she wrote them a check. The men were eventually caught and convicted, but the whole process indicated that Alice was growing increasingly vulnerable, and Jim suggested they look at retirement homes.
Alice’s difficulties here return to the conflict of autonomy versus safety. She wants to be able to live independently, but her old age and deteriorating mental and physical capacities are making it unsafe for her to be alone—which is why Jim suggests a retirement home to try to improve her safety.
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Medicine can determine whether a person’s decline is steep or more gradual. One study at the University of Minnesota focused on men and women over 70 who were living independently but had a high risk of becoming disabled. Half of them were randomly assigned to a team of geriatricians, while the other half were simply asked to see their usual physician. Within 18 months, 10 percent of each group died. But the patients who saw the geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.
This University of Minnesota study illustrates the importance of having geriatricians to treat the aging population. Recognizing what to look for in elderly care and knowing how to prioritize overall well-being over specific ailments provides significant benefits to those who receive that care.
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The geriatrics team simplified medications, controlled arthritis, and promoted overall health. But a few months after the study was published, the university closed the geriatrics division, because the services were too costly. This is a pattern all over the United States, which is why many doctors are choosing not to go into geriatrics. But the financial problems are indicative of a deeper reality: society does not prioritize doctors who bolster resilience in old age.
Just as Gawande emphasizes the importance of geriatrics, he illustrates the problems that geriatricians are facing across the United States. This is part of the reason Gawande brings these issues up, because he recognizes the importance of instituting reforms in medicine that prioritize geriatrics and incentivize people and places to support geriatricians.
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Gawande meets Felix Silverstone, a national leader in geriatrics for five decades, when the man is 87 years old. Felix can feel his own mind and body wearing down. He worked until he was 82, at which point he had to retire to take care of his wife, Bella, who became almost completely blind. They moved into a retirement community for people over 75, and when they needed to, they could upgrade to assisted living.
Felix’s story illustrates his struggle for autonomy not only for himself, but also so that he can help take care of Bella. Felix recognizes the difficulty in being able to care for someone else when he is also aging, which is why he opts for a place that can provide greater safety.
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The retirement community is expensive, which is true of retirement communities generally. More than half of the elderly living in long-term care facilities spend their entire savings and have to go on government assistance to afford it. Ultimately, many Americans go to nursing homes, which Felix hopes to avoid. He is most concerned about the changes in his brain, as he feels his cognitive ability slipping. Sometimes, he feels he is depressed.
Here the book highlights another important problem in the evolution of end-of-life care. While retirement communities have become commonplace, as more people live for longer periods of time, the financial aspect of long-term care is currently unsustainable and requires reform.
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What buoys Felix is a sense of purpose. He improves the health care services at his retirement home and forms a journal-reading club for retirement physicians. Most importantly, he cares for Bella. He knows that he has to be honest with himself about his progress, because if his health fails, he won’t be any help to her.
Even though Felix has sacrificed some autonomy by moving into a retirement home, he has been able to keep a good balance of independence by caring for Bella and remaining connected to his passions. This highlights the importance of purpose in making a person feel they have control over their lives.
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One evening, Gawande goes to dinner with Felix and Bella. Felix helps Bella sit and orders for her, as she can’t read the menu. When the food arrives, Felix tells Bella where the food is on her plate by the hands of a clock. She almost chokes on her food, and then he almost chokes as well. Gawande is amazed that Felix can still remain independent, care for Bella, and do his research.
Although Felix has a great degree of independence for his age, Gawande also notes that this clearly comes at the expense of safety for Felix and Bella, as both of them have some difficulty with simply eating.
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Felix has managed his old age well—particularly in finding a skilled geriatrician to help him. While there won’t be enough geriatricians to replace the retiring ones, geriatrics professor Chad Boult posits that the best strategy is to direct geriatricians to train primary care doctors and nurses to deal with the very old. This will help improve their care overall.
Here, Chad Boult highlights another way in which the medical fields could compensate for some of the issues that Gawande has raised—particularly the lack of doctors to care for the elderly. Directing geriatricians to train primary care doctors would help alleviate the doctors’ lack of knowledge and would improve the care (and lives) of the elderly generally.
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One day Gawande accompanies Felix on a drive to run an errand. Gawande is admittedly nervous to be in the car: the very old are the highest-risk drivers on the road. Felix is a capable driver, and he’s happy to be on the road. But Gawande knows that someday soon, Felix will have to give up his keys.
Cars are a key recurring symbol throughout the book, as many elderly people express dismay at having to give up this aspect of their lives. As a symbol of freedom and mobility, cars demonstrate how people often wish to hold onto the idea that they can remain independent. But cars can also be dangerous for the elderly and the people around them, and so often they have to give up that independence for greater safety.
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