4/5 stars

This is a little bit of a tricky one for me to review as I don’t generally read non-fiction. The same “rules” don’t necessarily apply. Though ultimately I’m still going by how it made me feel and think.

The book deals with problems of mortality and illness, as seen from the perspective of Dr Gawande. It covers essential topics that we all could do with thinking about, and it certainly should be compulsory reading for med students.

The setting is the US, but since the author is of Indian descent he also juxtaposes the situation in America with the “traditional family model” where the younger members of the family are expected to take care of the elderly, that’s still somewhat prevalent in India. He sees problems with both societies.

The first half (roughly) deals with old age and related sickness, nursing homes and assisted living options – what works and what doesn’t. Dr Gawande uses specific examples both of patients he has met with and institutions he has visited. Following some of the patients through multiple phases and chapters helps keep the story interesting and saves it from just being a factual retelling of various research – it has heart.

There are several problems in elderly care, one of which is the fact that there isn’t much money or prestige in it, meaning few doctors have an incentive to go into geriatrics or work specifically with the elderly, unless they have a burning passion for it. This in turn means that a lot of elderly people go to see their GP and are treated for each individual symptom with possibly a bunch of different medications, rather than holistically and in terms of the stage of life they’re in. As you get older your priorities shift and other things may be important to you.

Another problem is that a lot of nursing home type of facilities are basically storage units. Everything is according to a set schedule, it’s dictated when you get up, what you eat, when you shower, etc. Of course if you think about it, as an adult, that must be quite demoralising. You’re no longer in charge of even the most basic decisions in your life.  The basic need human need for meaning is often neglected. It basically doesn’t matter what you do, as long as you take your meds and follow your schedule. You don’t have a job, nobody is depending on you for anything. One of the successful examples Atul Gawande mentions is the Eden Alternative. It is successful for exactly this reason: it gives the elderly people meaning. They have plants and animals to take care of, maybe a garden to grow. Something so seemingly basic and simple made a huge impact on people’s lives and they were happier and healthier.

Granted, these kinds of homes probably cost more in the initial investment, but research show that less medication and overall medical care is needed, so in the end it could more or less even out. or even be cost beneficial And there’s the point that old people should still be entitled to as full a life as they can have, even if that costs more money.

The second half deals more with terminal illness and how a lot of doctors shy away from the difficult conversation, or they’re simply trained to focus only on medicine, facts and curing symptoms. Gawande talks of two types of doctors; the paternal doctor who will just tell you what to do because he or she knows best, and the informational doctor that will give you all the information about all the different drugs, surgeries and options you may have and then let you make a decision. There’s a third kind of doctor, a middle ground between these two that is seen as ideal. Obviously it’s good to have all the information, but it’s not always easy to interpret it. So the doctor should also have a conversation about what is most important to the patient and what treatment (or maybe even lack of treatment) can best facilitate that.

For instance in the case of a terminally ill cancer patient, is it best to just forge ahead with chemo therapy after chemo therapy in the hopes of eking out a few more months or a year of life, or is it better to remand the patient (if they want to, of course) to hospice care and let them have a higher quality of life and more freedom in the end than they would have had with continued treatment? Studies often found that people who went into hospice care ended up living longer and better than expected, though of course it’s not a cure nor a miracle – hospice is after all about making the dying more comfortable. But the body can only withstand so much stress, and in some cases medication does more harm than good.

Gawande also talks about the importance of being able to be in control of your own story, being able to be part of the decision of how you want to live the last part of your life, and die – as much as possible – on your own terms. He talks about the experiencing and remembering self, and how the human mind doesn’t necessarily work in a logical manner – we care about the narrative. So if we can get the ending we want, then the path leading there – even though it may be more painful – is of lesser importance. We prioritise a happy ending. And very few will feel as if months of hospital beds and chemo treatments are a happy ending. So, if in the end the treatment has no real chance of extending life – true life – by a meaningful amount of time for the patient, it may be better not to treat.

I found this book very interesting and informative. There’s lots of concrete examples both good and bad, references to relevant research and studies, yet it’s easy to follow as a layperson. And it’s engaging, because it’s brought down to a personal, human level.

It was hard to read, because it made me think about a lot of uncomfortable things, both in relation to myself and those around me – it’s never easy to be confronted with your own mortality and the idea that you too will probably get old and sick. It also dredged up a lot of memories from my father’s final days in hospital as well as really the last several years of his life. It’s of vital importance to think about these things though, and to have conversations about it before it’s too late.

Ultimately I guess I went into this expecting something more profound about the human experience and mortality than what I actually got. It is written by a medical man, and although it has warmth and compassion  – it’s clear that he cares deeply about the people and subjects he writes about – I’m missing something, larger, maybe spiritual. But overall a good and important read.