This book should be read by all those seeking a career in healthcare and all currently in a healthcare profession. It contains essential ideas for caring of the elderly, a practice that has been neglected in modern times. Dr. Gawande is an American surgeon and writer, with lots of experience in medicine. The book explores his experiences treating the elderly, the difficult conversations he has had with patients, family, and friends, as well as facing our own mortality. It is an aspirational book, aiming to incite change in our treatment of those close to death, questioning what is truly important towards the end.
This review serves to briefly outline the ideas introduced throughout the book, chapter by chapter. Being brief, it would be best to read the whole book to gain all the knowledge from it.
1 The Independent Self
‘Modernisation did not demote the elderly. It demoted the family.’
This chapter gives some background to the changing practices towards intergenerational living. With both older and younger generations seeking further autonomy, both have grown more independent of each other. Fewer grandparents rely on their children to take care of them until death. This increase of independence, which was desired by both young and old, does not hold up once serious illness occurs.
‘If independence is what we live for, what do we do when it can no longer be sustained?’
2. Thing Fall Apart
‘But in truth, no single disease leads to the end; the culprit is just the accumulating crumbling of one’s bodily systems while medicine carries out its maintenance measures and patch jobs.’
Whilst giving scientific reasons into the reasons for aging, Dr. Gawande uses some personal anecdotes to describe the decline of one’s health, the inevitability of it and one’s resistance to the eventual destination. This chapter forces the reader to face their own mortality and future decline.
‘We end up with institutions that address any number of societal goals – from freeing up hospital beds to taking the burden off families’ hands to coping with poverty among the elderly – but never the goal that matter to the people who reside in them: how to make life worth living when we are weak and frail and can’t fend for ourselves anymore’
Detailing the rise of the modern nursing home, this chapter explains the need for one during the 20th century, as well as the inherent problems with them, being more of a hospital then a home, causing unhappiness for residents in their final years. It highlights the need for a better system, that cares about their emotional needs, not just physical ones. Health, after all, is not all physical.
‘You’d think we would have burned the nursing homes to the ground.’
Focussing on alternatives to nursing homes, Dr. Gawande seeks a solution to our current problem. Family being one, but not always possible, with many family members being simply too busy to take care of their parents. The relatively new assisted living facilities, with the aim of ensuring as much independence for the elderly as possible. Though these had early success, their expansion led to a divergence from the original philosophy, returning to similar problems a nursing home experiences. Workers sometimes show little interest for what residents valued in life, not assisting them with living beyond a health perspective. The chapter also emphasises our need for empathy, as people in healthcare as well as children. We must constantly ask ourselves whether this is a place our parents would enjoy living in, rather than a place we feel comfortable for them to live in.
‘… a life designed to be safe but empty of anything they care about.’
5. A Better Life
‘In place of boredom, they offer spontaneity. In place of loneliness they offer companionship. In place of helplessness, they offer a chance to take care of another being.’
A more optimistic chapter, this details the experience of Dr. Bill Thomas as the new medical director of Chase Memorial Nursing Home. Being new, he was shocked at the despairing atmosphere. It was his new eyes that led to various reforms, such as introducing birds, cats, dogs, rabbits, hens, and visits from children. It was this abundance of life that improved conditions at Chase, decreasing deaths and drug costs. Reform of current nursing homes is possible with new ideas and attitudes towards care of the elderly. Using Josiah Royce’s philosophy, Dr. Gawande explains how meaning in life makes it worthwhile; the care of these new pets gave new meaning and purpose to residents. He gives further case studies beyond Chase, shining a positive light on the future of healthcare.
6. Letting Go
Moving on from just elderly care, Dr. Gawande begins to critique our approach to end of life care, of which there are generally two approaches: treating to avoid death or ensuring a good final period of life. Cancer treatment, for example, can be very draining and cause suffering. This may get in the way of a ‘good death’, and often doesn’t change the inevitability of death, sometimes making it sooner. Our instinct is often to fight the illness, die in intensive care than accept it. It is very difficult to let go, both for patients and loved ones. Hospice care, though it treats, has different priorities: freedom from pain, mental awareness, going out with family etc. It is often tailored to the individuals’ desires, and sometimes leads to living longer than originally predicted
7. Hard Conversations
‘Interpretive doctors ask, “What is most important to you? What are your worries?” Then when you know your answers, they tell you about the red pill and the blue pill and which one would most help you achieve your priorities’
Dr. Gawande tells the story of his father, suffering from a tumour in his spinal cord. His and his family’s experience through this ordeal gave insight into treating those that are facing serious illnesses. He states the importance of being an interpretive doctor (coined by Ezekiel and Linda Emmanuel) rather than a paternalistic approach or informative approach. The former follows a doctor-knows-best model, with little room for patient autonomy. The latter is when the doctor states the facts and leaves the decision up to the patient., with complete autonomy. Though patient autonomy is necessary, this model still has flaws. It is often difficult for patients to know what choice is best for them, even with facts and statistics. ‘Shared decision making’, as part of the interpretive model, does what is best for the patient and requires plenty of empathy from the doctor. The Emmanuels’ paper may be worth reading for those who wish to know more about this relationship.
Death and mortality are often taboo topics, with discussion often being avoided. This is detrimental to the interpretive model. The patient must be open about their desires to their doctors and their loved ones (typically the harder conversation to have).
‘Here is what a different kind of care – a different kind of medicine – makes possible, I though to myself. Here is what having a hard conversation can do.’
‘Courage is strength in the face of knowledge of what is to be feared or hoped.’
This chapter highlights the importance of courage for those facing death: courage to confront the reality of mortality (identifying desires and fears) and to act on the truth we find (fulfilling these desires and mitigating the fears). Surgery, for example, offers the chance for better living conditions, but the chance of also making the current condition worse and causing more suffering, making it difficult to decide. Deciding whether desires or fears should matter most is a difficult task. However, it is done with the help of doctors and loved ones, with their guidance making the final path clearer.
‘I am leery of suggesting the idea that endings are controllable. No one ever really has control. Physics and biology and accident ultimately have their way in our lives. But the point is that we are not helpless either. Courage is the strength to recognise both realities.’
Once again, this book should be read by all those involved in healthcare. We need more interpretive doctors in the world of medicine, to ensure the final days of patients and the elderly are not filled with despair, but rather fulfilment.