Being Mortal: Chapter 8 Summary & Analysis

In 380 B.C., Plato wrote about courage, positing that courage is strength in the face of fears or hopes. In aging and sickness, there must be courage to confront the reality of mortality: to seek out the truth of people’s fear or hope. But aging and sickness also require the courage to act, and to determine whether one’s fears or one’s hopes matter most.

When Gawande returns from Ohio, he gets a late-night page that Jewel Douglass is vomiting once more. In the hospital, he finds that her cancer has grown and multiplied, and her abdomen fills with fluid. But she still keeps a good attitude. Gawande realizes that he could suggest a whole new range of treatments and surgeries, or he could talk about hospice.

Instead of overwhelming Douglass with her options, Gawande asks what her fears and goals are and what tradeoffs she’s willing to make. She says she wants to be without pain, nausea, and vomiting; she wants to eat and get back on her feet; she wants to get back home and be with people she loves; and she wants most to go to a wedding taking place in two days. Gawande knows an operation would never let her get to the wedding, and chemotherapy would have a slim chance of improving her situation while providing major drawbacks. Gawande recommends this option: to drain the fluid in Douglass’s abdomen, give her medication, and discharge her.

That same night, however, Douglass comes back to the hospital, as her vomiting returned. Surgery is now the best course of action to restore her ability to eat, but she’s afraid of the tubes and the complications. Her greatest fear is greater suffering. Gawande estimates that he has a 75% chance of making her future better for a little while, with a 25% chance of making it worse.

The brain gives two ways of evaluating suffering, as laid out by Nobel-Prize winning behavioral economist Daniel Kahneman in Thinking, Fast and Slow. He studied a group of patients undergoing colonoscopy and kidney stone procedures. They rated their pain both during and after the procedure. Patients typically had low to moderate pain punctuated by spikes of significant pain while they experienced it. But afterward, their ratings were predicted by an average of the pain at two moments: the worst moment, and the very end, not according to the total amount (the Peak-End rule).

Kahneman posits that there is an “experiencing self” that endures every moment equally and a “remembering self” that only remembers the peak and the end. When it comes to life, both matter: we don’t want to endure long pain and short pleasures, but certain pleasures can make enduring suffering worthwhile. The peaks and the ending are important, and this is the dilemma that Jewel Douglass faces. Should she focus on the worst things she might endure and the very end, or the overall amount of suffering.

Douglass tells Gawande that she wants to be able to spend time with her family but doesn’t want to be risky. With these instructions, Gawande tells her that he can look around at her intestines and unblock them only if he believes he can do it fairly easily without taking unnecessary risks. When Gawande performs the surgery, he realizes that her intestines are completely tethered by tumors, and trying to get them free would be too risky. So instead, they simply drain her stomach and abdomen and close her up.

When Douglass wakes, she thanks Gawande for trying, and for relieving her nausea and pain. Three days later, she leaves to go home with hospice to look after her. A few days later, Gawande visits her after work. She feels like she’s slipping, but she’s glad to see old friends and relatives all day. They talk about her memories, and she says that she is at peace. Gawande feels that Douglass’s ending is a good one. Two weeks later, her daughter sends Gawande a note that Douglass passed away, and that the family had a perfect ending with her.

The question arises as to how far our control should extend at the very end. “Assisted suicide” is the term, but advocates prefer “death with dignity.” We recognize some version of this right when we allow people to refuse food or water or medications. Cardiologists accept that patients have the right to have their doctors turn off their pacemaker if they want it. We recognize the necessity of drugs that reduce pain even if they speed death. We are running up against the philosophical distinction between giving people the right to stop artificial processes that prolong their lives and the right to stop natural processes that do so.

The debate is about what we fear most: the mistake of prolonging suffering or the mistake of shortening life. We stop the healthy from committing suicide because we recognize that their suffering is often temporary. Indeed, only a minority of people saved from suicide make a repeated attempt: the vast majority eventually report being glad to be alive. But this is not the case in terminally ill patients who face increasing suffering. In places that allow physicians to write lethal prescriptions (the Netherlands, Belgium, Oregon, Vermont), they can do so only for terminally ill adults who face unbearable suffering, make repeated requests, do not act out of depression or mental illness, and who have a second physician confirming that they meet the criteria.

Still, Gawande worries about actively assisting people with speeding death. By 2012, one in 35 Dutch people sought assisted suicide at their death, and this is not a measure of success. The goal is a good life to the very end. The Dutch have been slower to develop palliative care programs. But sometimes suffering is unavoidable, and helping people end that suffering may be necessary. Gawande supports laws to provide these prescriptions—particularly as about half the people given the drugs don’t use them. But we should also focus on improving the lives of the ill, not just their deaths.

One day, Gawande gets a call from the husband of Peg Bachelder, his daughter’s piano teacher. Peg has been undergoing cancer treatments for a rare soft-tissue cancer for over two years, but now she has run out of treatment options. She knows that she is going to die very soon, but she fears more pain, losing bodily control, and being unable to leave the hospital. Gawande knows that some in her position, offered death with dignity, might have taken it as the only chance for control. But Gawande convinces her to try hospice, which would at least get her home and might help her more than she thinks.

A few days later, Peg calls and wants to resume teaching Gawande’s daughter. Hospice allowed her to manage her daily difficulties and regain the things she loves, which in turn reduces her anxieties. She lives a full six weeks, giving her the opportunity to host concerts with her students and say goodbye to dear friends. Peg gets to share memories, pass things on, settle relationships, establish legacies, and make peace with God. She gets to end her story on her own terms.

Eventually, Gawande’s father’s story ends as well. After he starts hospice in the early spring, he has difficulty regaining a sense of normalcy as his body continues to break down, but he has good days and weeks as well. He still has dinner parties and watches movies and connects with friends. But his weight drops, and he sends some garbled emails.

On Saturday, August 6, Gawande’s mother calls, explaining that his father isn’t waking up after taking a strong dose of pain medications. She calls the hospital, not the hospice agency, and they bring him to the emergency room. He has pneumonia and is at an unsurvivable oxygen level. They ask Gawande’s mother whether they should intubate his father and move him to the ICU. But per Gawande’s father’s wishes, she tells them not to intubate him.

Gawande realizes that this is probably the end, but his mother and sister aren’t certain. Gawande and his sister both book flights to Ohio, and later that afternoon, Gawande’s father wakes up. He grows alert and unhappy about being in the hospital in deep pain—they fear he will lose consciousness again on the pain medications. But due to his protests, they give him an injection for the pain and send him home.

Gawande’s father’s greatest pain is his from the tumor. He starts to sleep for longer periods. But even in his last few days, he still eats well, sorts photos, and gives instructions about unfinished projects. Gawande gives him morphine every two hours, and the family sits by his bedside for long periods of time. On his second to last day, the family gets him into a wheelchair and he sits looking outside with them. But he decides that eating is prolonging his death, and that he’d rather sleep than be awake. During Gawande’s father’s final bout of wakefulness, Gawande shows him pictures of his grandchildren, and he smiles widely. Then he descends into unconsciousness again, and finally, his breathing stops.