Being Mortal: Medicine and What Matters in the End

by Atul Gawande

“intimacy at a distance.”

In Asia, where the idea of an elderly parent being left to live alone has traditionally been regarded as shameful—the way my father saw it—the same radical shift is taking place.

Choices for the elderly have proliferated.

offered the prospect of an active retirement of recreation and dining out with others like them to share it with.

Honestly a fantastic counter argument… Do we, the younger generation, really care for our elderly like those in asia do?

Modernization did not demote the elderly. It demoted the 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 The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.

But in truth no single disease leads to the end; the culprit is just the accumulated crumbling of one’s bodily systems while medicine carries out its maintenance measures and patch jobs.

In a sense, the advances of modern medicine have given us two revolutions: we’ve undergone a biological transformation of the course of our lives and also a cultural transformation of how we think about that course.

There is, he told me, “no single, common cellular mechanism to the aging process.” Our bodies accumulate lipofuscin and oxygen free-radical damage and random DNA mutations and numerous other microcellular problems. The process is gradual and unrelenting. I asked Silverstone whether gerontologists have discerned any particular, reproducible pathway to aging. “No,” he said. “We just fall apart.”

As medical progress has extended our lives, the result has been what’s called the “rectangularization” of survival.

Today, we have as many fifty-year-olds as five-year-olds. In thirty years, there will be as many people over eighty as there are under five. The same pattern is emerging throughout the industrialized world.

And partly, whether we admit it or not, a lot of doctors don’t like taking care of the elderly. “Mainstream doctors are turned off by geriatrics, and that’s because they do not have the faculties to cope with the Old Crock,”

The single most serious threat she faced was not the lung nodule or the back pain. It was falling.

The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world.

The men were convicted and sentenced to prison, which should have been satisfying for Alice. But instead the whole process kept the events, and the reminders of her growing vulnerability, alive and lingering when she would have dearly loved to have set them behind her.

If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices. Instead, it was just geriatrics.

“Economically, it has become too difficult,” Boult said. But the dismal finances of geriatrics are only a symptom of a deeper reality: people have not insisted on a change in priorities. We all like new medical gizmos and demand that policy makers ensure they are paid for. We want doctors who promise to fix things. But geriatricians? Who clamors for geriatricians? What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited.

Ultimately, the average American spends a year or more of old age disabled and living in a nursing home (at more than five times the yearly cost of independent living), which is a destination Felix was desperately hoping to avoid.

An absolutely alarming cost...

how we seek to spend our time may depend on how much time we perceive ourselves to have.