January 12, 2017

We Are All Mortal: The Importance of End of Life Care

We are all mortal

The tragedy of old age and death cannot be fixed by medicine. 

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What’s it about?

A surgeon, Atul Gawande, writes a book on mortality, the inevitability of decline and the how our medical systems fails us in the end. No matter how careful or healthy we are, we – like everyone else – will one day die. Most likely after a long period of decline and debility.

We Are All Mortal:

  1. The average Westerner spends a year or more disabled and living in a nursing home. The change from traditional ways of life, where families live together and children support their parents, has many reasons. These include increased age spans, improved medical practice and financial independence.
  2. Many elderly enjoy their independence and report greater contentment than the young do. Decline is inevitable though and there are three main types. Fatal diseases, such as an incurable cancer, for which treatment can hold death off for a short period of time. Chronic diseases, such as emphysema, treatable, but relapses wear the body down. Finally, there is frailty, the accumulated crumbling of one’s systems.
  3. The major threat to old people is that they will fall down. Most falls are due to muscle weakness and poor balance, and from taking multiple medications.  About 20 percent of elderly people who fall and fracture a hip will develop complications within a year that they will never recover from.

We Are All Mortal:

  1. Nursing homes arose as a solution for hospitals that needed to empty their beds of patients who had nowhere else to go. They were not foremost designed as places where the elderly would be content. There quality varies. In the worst, residents sleep two to a room and are medicated when awake. All place safety before autonomy and are designed to appeal to the residents children not the resident themselves. Many elderly dislike the lack of control and the unfamiliarity of their surroundings, preferring their own homes, despite the dangers.
  2. Death comes for most people after a long medical struggle. No one wants to give up, it’s even harder if the victim is still young. Even when physicians know how bleak the outcome is they often hide it from their patients. Survival statistics form a long bell-shaped curve in which a few people live longer than the norm. Most believe they can beat the odds, and physicians are loath to discourage them.
  3. When the suffering outweighs the benefits, the author favors palliative care. He cites research that shows that those who see a palliative care specialist stop treatment sooner, enter hospice earlier, experience less suffering at the end of their lives—and live 25 percent longer.

Quote

The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.

No one ever has control. Physics and biology and accident have their way in our lives. But the point is that we are not helpless either. Courage is the strength to recognize both realities. We have room to act, to shape our stories, though as time goes on it is within narrower and narrower confines.

A few conclusions become clear when we understand this: that our most cruel failure is how we treat the sick and the aged is the failure to recognize that they have priorities beyond 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.

Hard Facts

Our mortality is often something we need reminding about.  Around the age of forty a person begins to lose muscle mass and power. As we age lung capacity decreases, bowls slow down, glands stop functioning, even our brain shrinks. By the age of seventy there is a inch of space in the skull that wasn’t there before and falls can easily lead to cerebral bleeding.

The progress in medical and public health has been remarkable. We no longer keel over at thirty. For most of us the end is not sudden and dramatic, but a slow deterioration of health. A decline,  then a plateau, then another deterioration. Travelling along these downhill stretches we often regard the declines as embarrassments.

We regard dependence as weakness and hold up examples of the long tail as something we should all aspire to. Often the medical system supports us in these aspirations, providing minimal-benefit treatments or striving to keep us alive no matter the cost – both physically and mentally.

Hard talks matter. Before under-going any treatment Gawande implores us discuss and understand what matters to us most and what we are willing to risk.

Take Away Points and Context

  • The tragedy of old age and death cannot be fixed by medicine and as society we need to find a better way to deal with it.
  • Several studies have shown that nursing homes that have more stimulation and autonomy increase both longevity and the happiness of patients.
  • Endings matter and it important to understand a person’s priorities, what their fears are, what they can accept what they cannot.

Full article:

A Better Way Out

Marcia Angell

 

Being Mortal: Medicine and What Matters in the End

by Atul Gawande
Metropolitan, 282 pp., $26.00

We Are All Mortal: End of Life Care’s Importance. Your comments welcome below.

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Matt

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