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Wednesday
I’m currently appreciating Atul Gawande’s Being Mortal: Medicine and What Matters in the End. Gawande, who is a surgeon, professor at Harvard’s school of health, and advisor to presidents, has special insight into how doctors get things wrong. Too often, he says, they focus only on fixing the medical problem rather than looking at what the patient most needs, especially when it comes to quality of life.
Speaking for myself, if I am going to have a prolonged end, I would like that end to be like the one that Teiresias forecasts for Odysseus:
Then a seaborne death
soft as this hand of mist will come upon you
when you are wearied out with rich old age,
your country folk in blessed peace around you . . .
My mother came close to this: she died at home just short of her 97th birthday, with Julia and me at her side. This was only possible, however, because we had moved in with her and because I chose to retire at 67 rather than 70, my original target date. Our two sons have informed us that they will not do the same for us.
Julia and I are trying to be deliberate in how we ourselves move forward. We remain active (tennis for me, yoga/tai chi for her), and we are working with a consultant about “aging well.” This involves a daily exercise regime designed to work on balance, muscle strength, and flexibility. We also pay special attention to our diet and we have formulated a Plan B, looking at retirement centers near one of our sons.
Regardless of what we do, however, our bodies and minds will begin breaking down, either steadily or all in a rush. Gawande’s book opens with a quotation from Philip Larkin’s poem “Ambulances”: “They come to rest at any kerb:/ All streets in time are visited.” More ominously, he also borrows a passage from Philip Roth’s novel Everyman: “Old age is not a battle. Old age is a massacre.”
His concern is that the health field is underfunding gerontologists, focusing instead on disease specialists—and that, as a result, the wrong issues are getting addressed. Old age should be regarded more as an existential challenge than a medical one, he essentially says.
I particularly like how he turns to Tolstoy’s novella The Death of Ivan Ilych to address the issue. Ivan Ilych is a respected magistrate whose life “revolves mostly around petty concerns of social status.” Then a seemingly minor accident—he falls while installing a curtain—leads to a painful medical condition that no one can cure. None of the expensive doctors brought in “can agree on a diagnosis, and the remedies they give him accomplish nothing. For Ilyich, it is all torture, and he simmers and rages at his situation.” Or as Tolstoy puts it,
What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result.
Ivan Ilyich is furious that his doctors and friends can’t see his mounting anguish and fear of death. Tolstoy writes,
No one pitied him as he wished to be pitied. At certain moments after prolonged suffering he wished most of all (although he would have been ashamed to confess it) for someone to pity him as a sick child is pitied. He longed to be petted and comforted. He knew he was an important functionary, that he had a beard turning grey, and that therefore what he longed for was impossible, but still he longed for it.
Gawande says that modern medicine’s response to Ivan Ilyich would be the same as that of his doctors: it tries to fix and then hen, when all else fails, it walks away. It doesn’t grapple with (I’m quoting Tolstoy here) the “chasm of perspective between those who have to contend with life’s fragility and those who don’t” or who fail to grasp “the particular anguish of having to bear such knowledge alone.” They don’t realize that that what Ilyich most desires is comfort and companionship.
Fortunately, he’s not as alone as he thinks. His servant Gerasim understands what he feels, and in his subsequent care, we are given a vision that retirement centers and nursing homes—and really, all of us—should aspire to. As Gawande points out,
Gerasim sees that Ivan Ilych is a suffering, frightened, and lonely man and takes pity on him, aware that someday he himself would share his master’s fate. While others avoid Ivan Ilyich, Gerasim talks to him. When Ivan Ilyich finds that the only position that relieves his pain is with his emaciated legs resting on Gerasim’s shoulders, Gerasim sits there the entire night to provide comfort. He doesn’t mind his role, not even when he has to lift Ilyich to and from the commode and clean up after him. He provides care without calculation or deception; and he doesn’t impose any goals beyond what Ivan Ilych desires.
In Tolstoy’s words, Gerasim “did it all easily, willingly, simply, and with a good nature that touched Ivan Ilyich.”
Gawande says that this “simple but profound service—to grasp a fading man’s need for everyday comforts, for companionship, for help achieving his modest aims—is the thing that is still so devastatingly lacking more than a century later.”
Tolstoy’s brilliance lies in part in how he enters the minds of his characters, and it is such empathy that is called for in dealing with our elderly infirm. Gawande’s book, in addition to laying out the stark facts, also shares inspiring stories of people who have re-envisioned senior centers, transforming them into something other than holding pens for the dying. We need the kind of imagining that literature encourages and fosters.
A semi-humorous story: When my mother was experiencing heart issues in her late 80’s, her cardiologist recommended a new heart valve. In response, she declared that she’d rather die than have open heart surgery, where the breastbone is sawed open. Thinking this was the only option, Julia started talking about what a wonderful life she had had—to which the cardiologist tartly interjected, “We are no longer in the practice of putting our elderly on ice floes.”
It so happened that there was an alternative—modern medicine can reach the heart through the thigh—and my mother got a new valve, which made her final years much more comfortable. So the cardiologist was right, and I find myself laughing at this now.
But apparently there was a moment in the operation when it wasn’t clear that the thigh approach would work and they contemplated sawing open the breastbone. I think of how utterly pissed my mother would have been had they had done so. She would have opted for that ice floe.
