Being Mortal: Illness, Medicine and what Matters in the End

Gawande’s wife’s grandmother serves as an example of how nursing homes can adversely impact the mental health of the elderly. When her physical health begins slipping, it becomes clear that she needs assistance. When moved into a nursing home, however, she becomes despondent. After an active and independent life, Hobson responds poorly to nursing staff telling her when to wake, what to eat, when to bathe, and when to go to bed. The author insinuates that there could’ve been a more meaningful way for her to pass rather than dying alone with chest pains, coughing up blood.

The author’s grandfather died at the age of 109, after hitting his head falling off a bus. Unlike the American elders that Gawande treats, he lived the way he wished in his old age and died surrounded by family. The author cites his grandfather’s waning years as an example of a way of living that has become obsolete in the modern world, as more people now live longer and fewer households are multigenerational. 

Gawande admires Silverstone, a geriatrician, because of his dignified and courageous approach to death. Silverstone accepts his bodily failings as they arise. Given his specialization, it is not surprising to the author that Silverstone does not attempt risky or invasive proceduresfor himself or his wife, Bella. When his wife becomes very ill, he works to care for her with some assistance rather than having her relocated to a setting where she would get nursing care. After she passes, Silverstone is glad he made that decision.

Watching geriatrician Bludau work, Gawande is initially surprised. The author expects Bludau to treat his elderly patient’s tumor which might be cancer. Instead, Bludau treats his patient’s balance and nutrition, making sure that she is steady on her feet and consuming enough calories.

Jean is a patient of geriatrician Juergen Bludau. Her life at age eighty-five reminds Gawande of his wife’s grandmother’s life, before she was moved to a nursing home. Jean is fairly mobile and independent, with grown children nearby who look in on her. She has had cancer before and there is a chance that it may have returned but to Gawande’s surprise, Bludau doesn’t pursue this issue. Instead, he asks Jean to tell him about her life, to discuss her appetite and her schedule and to alert him to any pain she is experiencing. He ends up referring her to a podiatrist, so she can remain steady on her feet, and helps her meal plan so she can continue to take in adequate daily calories. When Gawande checks in on her a year later, she is still doing well, living independently and has gained two pounds.

Sara is in her thirties and pregnant when she is diagnosed with advanced lung cancer. Because she is so young, her family cannot fathom her condition being fatal. Sara endures one exhausting treatment after another and finally dies of pneumonia. Even at the very end, her loved ones cannot imagine her demise. The author portrays her as suffering partly because she felt compelled to fight so hard against impossible odds.

Physician Bill Thomas did the unthinkable in his work with assisted living communities. He introduced elements that ran counter to the established ideas of hygiene and order by bringing pets, plants and regular contact with school children into his facilities. Though many initially balked at his plans, he was able to demonstrate positive results for his residents’ overall health. His communities of Eden Alternative and Green House attempted to address mental health and quality of life more directly for the elderly.

Brown was inspired to create an alternative to the standard nursing home after watching her mother suffer in a home that would not allow her any independence or even afford her basic human dignity. Brown’s vision of “living with assistance” consisted of seniors residing in homes where they were still mobile and free to make their own decisions but could quickly access medical care as needed or desired.

With Jewel Douglass, Gawande more than simply offer her options in how to deal with her terminal cancer. He also listens as she answers his questions about her wishes and fears. Her death is ultimately more peaceful than it might’ve been if she felt pressured into endless medical procedures.

Early in the book, Gawande cites the conversation he had—and the one he failed to have—with Lazaroff, who asked Gawande to explore every medical option for him. Gawande regrets not talking to Lazaroff more frankly and offering the guidance that he thinks doctors need to offer patients approaching the end of their lives. Instead of dying on a ventilator, Lazaroff might have lived out his final moments in a more meaningful way if Gawande had fully discussed what Lazaroff really wanted and feared.

Lou Sanders is another elder who is unhappy being in an assisted living facility, until his daughter is able to find a home designed by Bill Thomas, where Lou can continue to be a night owl, political junkie and card shark. Lou doesn’t fit in at the traditional assisted living home, where resident activities feel geared towards women and he is told when to go to bed. Though Lou needs medical care, he also needs to be able to continue to live his life on his terms.

Peg is Gawande’s daughter’s piano teacher and a woman he counts as a personal friend. Learning that her condition has been pronounced as terminal is difficult for Gawande and his family. It is even more painful for him to see Peg and her husband angry and confused as they grapple with what to do next. The doctors do not offer any definitive plans, treatment wise, but she is encouraged to remain in a hospital setting. Using a guidance-style approach, Gawande convinces the couple that she is better off at home, in hospice care, where she can enjoy the company of relatives and students. Gawande’s daughter participates in a final recital given in Peg’s house and the author describes the experience as moving and meaningful for all.