33 pages • 1 hour read
Atul GawandeBeing Mortal: Illness, Medicine and what Matters in the End
Nonfiction | Book | Adult | Published in 2014A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Introduction-Chapter 2Chapter Summaries & Analyses
Introduction Summary
Gawande begins by noting that as comprehensive as his medical education was, the issue of mortality was never truly addressed. The only time he remembers discussing mortality was during a Patient-Doctor seminar geared towards making physicians more humane and responsive. In that course, he and classmates read and discussed Tolstoy’s novella, “Death of Ivan Ilyich.” Gawande reflects on the suffering of the titular character, which was made so intense because no relative, friend or neighbor was willing to openly admit that Ilyich was dying. Instead, he was told he was simply ill. More and more expensive doctors were sent for, and Ilyich was forced to undergo pointless and supposedly curative measures. As a doctor, Gawande notes that what Ilyich clearly wanted, and needed, was someone to help him in his fear of death and to offer him companionship at the end. Gawande connects his thought on this book with his own experiences with a patient, Mr. Lazaroff. Mr. Lazaroff’s prostate cancer had spread throughout his body yet he underwent a surgery to have a tumor removed from his spine. Though the surgery was technically a success, Mr. Lazaroff never recovered from the procedure and spent his last days on a ventilator. Gawande thought then and now that it would have been wiser to simply offer Mr. Lazaroff comfort care, rather than a fantasy that he could recover.
Chapter One Summary: “The Independent Self”
Gawande reflects on the end-of-life experiences of his wife’s grandmother, Alice Hobson. Widowed young, she was independent and free-spirited. She was in her eighties andlived alone. Gawande contrasts this with his own grandfather, Sitaram Gawande, whose geriatric years were spent in the traditional fashion in India: surrounded by extended family who did not contradict his decisions as patriarch to do as he liked in his waning years. These observations led Gawande to analyze how family structures have changed over the years, with families frequently living more farther away from one another. He notes that his grandfather’s arrangement, in which multiple generations all lived under one roof, is hardly the norm for many parts of the world. The result of this has been the growth of nursing homes, or retirement communities.
Chapter Two Summary: “Things Fall Apart”
Gawande discusses the ways in which the routine pattern of death has changed in recent history. Medical progress has made it far less likely that an individual will rapidly succumb to one sudden illness. The deaths of his grandmother, who passed quickly after contracting malaria, or his wife’s grandfather, who dropped dead from a heart attack, are now the exception to the rule. Now, most often, death finally arrives after accumulating chronic issues. Death is no longer sudden.
Gawande is troubled by the way popular culture presents the inevitable deterioration of the body as a personal failure rather than an inevitable process. He references his conversation with geriatrician Felix Silverstone, who notes that his specialization is unpopular because it offers no hope of cheating death, no glamorous heroics. Gawande recalls watching another geriatrician, Juergen Bludau, treat a patient, Jean Gavrilles. Gavrilles, like Alice Hobson was in her eighties and living alone. Though nodules on her lung suggested that a previous bout of cancer was back and aggressively metastasizing, Bludau elected to treat Gavrille’s feet, to improve her balance and reduce her likelihood of falls. He also discussed ways for her to increase her calorie count and assisted her in making sure a family member would dine with her regularly. Gawande was surprised at the time that Bludau did not address his patient’s cancer but according to the geriatrician it was quality of life and supporting his patient’s freedom and ability to function independently that mattered most.
For Alice Hobson, however, independent living becomes more and more difficult and finally she is moved to a nursing facility. Felix Silverstone moves to a retirement community as well,and Gawande visits him. Silverstone discusses how difficult it was to pack up the home he and his wife, Bella, raised their two sons in but as a physician, he is especially able to notice his own decline. Silverstone struggles with bouts of depression but feels a purpose in life in caring for his wife, who has lost her sight and has memory problems.
Introduction-Chapter 2 Analysis
Gawande begins his book by acknowledging just how underprepared he was as a doctor when it came to dealing with death. Death is the natural enemy of the medical profession and clearly not one they can permanently vanquish. Given the inevitability of death, what is a doctor supposed to do for a patient? For Gawande, Tolstoy’s novella serves as a guide of sorts. The main character, Ilyich, suffers acutely and alone because his doctors and loved ones simply cannot face the inevitably of his death and insist on telling him and themselves that he is only ill. The only real solace is offered by a servant, a boy named Gerasim, who takes pity on Ilyich and allows the main character to express his fears of death. Everyone else avoids the dying man altogether. Only his servant is willing to keep him company and offer him solace without any promises or any advice.
Gawande turns to this work again and again in his writing. The author finds himself wishing he had been more like Gerasim for his advanced-stage cancer patient Joseph Lazaroff. Lazaroff asked the doctor to do everything that he could to keep him alive but Gawande feels now that he did not adequately follow up on that request when the patient made it. In retrospect, he wishes he had talked with Lazaroff to know more about how the patient wanted to spend his last days and what trade-offs he was willing to make. Gawande went ahead with a risky surgery on Lazaroff, all in the name of treating him as someone who might recover from his illness. While the surgery was a technical success, Lazaroff never recovered from the procedure and died while on a ventilator. In the name of securing him a little more time and avoiding a hard conversation, Gawande facilitated an unpleasant end for his patient. His treatment of Lazaroff functions as one of the examples in the book in which Gawande thinks that he failed his patient, and himself, because he clung to outmoded and unsuccessful views of death and dying.
Gawande also considers the way contemporary American culture deals with the elderly, first through his analysis of Alice Hobson, his wife’s grandmother. In her old age, Hobson lived alone and as independently as she could. Being a feisty and free-spirited soul, independence suited her fine, though her living arrangement was not without complications (she falls and has a minor fender bender). Gawande contrasts Hobson’s solitary old age and slow decline with the twilight years of his grandfather in India, who was surrounded by extended family who catered to him and cared for him until the end, always viewing him as the indispensable patriarch. Gawande postulates that care of the elderly has changed in part because life expectancy has increased. He also notes that family structures have shifted profoundly, with global economic development prompting individuals to often move far from their family home. In some ways, growing independence is beneficial for both child and elder. As the author states:
[m]odernization did not demote the elderly. It demoted family. It gave people—the young and the old—a way of life with more liberty and control, including the liberty to be less beholden to other generations. The veneration of elders is gone but not because it has been replaced with the veneration of youth. It’s been replaced by the veneration of the independent self(44).
Gawande begins mapping out how nursing homes sprung into existence and how those facilities have improved (or failed to improve) over the course of recent decades. First pioneered by real estate developer Del Webb, who coined the phrase “retirement community” in 1960, when he launched Sun City, in Phoenix, Arizona, the idea of elders living apart from society in a separate community was initially controversial. However, Del Webb was able to promote his community by advertising that the facilities were not demoting the importance of family but rather prioritizing liberty and control for the elderly.
Complicating all of this, Gawande believes, is a lack of understanding about how aging and death actually occur. He notes that fewer people now die of sudden illness, as has been the case for most of human history. Instead, due to medical advances that render most conditions treatable, most people now experience a slow decline that culminates in death. Aging and bodily wear and tear are natural, yet medical advances make us slow to confront inevitable bodily changes. The writer notes:
We’re always trotting out some story of a ninety-seven-year-old who runs marathons as if such cases were not miracles of biological luck but reasonable expectations for all. Then, when our bodies fail to live up to this fantasy we feel as if we somehow have something to apologize for (52).
Gawande laments the decline of the field of geriatrics and reports the effective treatment offered by Juergen Bludau, a chief geriatrician. Rather than doing biopsies or surgeries, these geriatricians simplify medications, control arthritis, and monitor nutrition and mobility. Gawande states, “The geriatrics teams were doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications […] They looked for worrisome signs of isolation and had a social worker check that the patient’s house was safe” (77). Gawande references the experiences of Felix Silverstone, a retired geriatrician, as a more meaningful way to deal with aging, one that accepts the process and doesn’t involve endless, agonizing methods to try and stave it off.
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