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Preview — Being Mortal by Atul Gawande
Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.
You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they ...more
But one thing he could never get used to was how we treat our old and frail—leaving them to a life alone or isolating them in a series of anonymous facilities, their last conscious moments spent with nurses and doctors who barely knew their names. Nothing could have been more different from the world he had grown up in.
Given the opportunity, both parents and children saw separation as a form of freedom. Whenever the elderly have had the financial means, they have chosen what social scientists have called “intimacy at a distance.”
Whereas in early-twentieth-century America 60 percent of those over age sixty-five resided with a child, by the 1960s the proportion had dropped to 25 percent. By 1975 it was below 15 percent. The pattern is a worldwide one. Just 10 percent of Europeans over age eighty live with their children, and almost half live completely alone, without a spouse. 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. In China, Japan, and Korea, national statistics show the percentage ...more
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 The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.
It happens in a bewildering array of ways. Hair grows gray, for instance, simply because we run out of the pigment cells that give hair its color. The natural life cycle of the scalp’s pigment cells is just a few years. We rely on stem cells under the surface to migrate in and replace them. Gradually, however, the stem-cell reservoir is used up. By the age of fifty, as a result, half of the average person’s hairs have gone gray.
Your chances of avoiding the nursing home are directly related to the number of children you have, and, according to what little research has been done, having at least one daughter seems to be crucial to the amount of help you will receive.
what makes life worth living when we are old and frail and unable to care for ourselves? In 1943, the psychologist Abraham Maslow published his hugely influential paper “A Theory of Human Motivation,” which famously described people as having a hierarchy of needs. It is often depicted as a pyramid. At the bottom are our basic needs—the essentials of physiological survival (such as food, water, and air) and of safety (such as law, order, and stability). Up one level are the need for love and for belonging. Above that is our desire for growth—the opportunity to attain personal goals, to master ...more
When people reach the latter half of adulthood, however, their priorities change markedly. Most reduce the amount of time and effort they spend pursuing achievement and social networks. They narrow in. Given the choice, young people prefer meeting new people to spending time with, say, a sibling; old people prefer the opposite. Studies find that as people grow older they interact with fewer people and concentrate more on spending time with family and established friends. They focus on being rather than doing and on the present more than the future.
But Carstensen’s research found exactly the opposite. The results were unequivocal. Far from growing unhappier, people reported more positive emotions as they aged. They became less prone to anxiety, depression, and anger. They experienced trials, to be sure, and more moments of poignancy—that is, of positive and negative emotion mixed together. But overall, they found living to be a more emotionally satisfying and stable experience as time passed, even as old age narrowed the lives they led.
question. If we shift as we age toward appreciating everyday pleasures and relationships rather than toward achieving, having, and getting, and if we find this more fulfilling, then why do we take so long to do it? Why do we wait until we’re old? The common view was that these lessons are hard to learn. Living is a kind of skill. The calm and wisdom of old age are achieved over time.
Carstensen barely survived. She had a serious head injury, internal bleeding, multiple shattered bones. She spent months in the hospital. “It was that cartoonish scene, lying on my back, leg tied in the air,” she told me. “I had a lot of time to think after the initial three weeks or so, when things were really touch and go and I was coming in and out of consciousness. “I got better enough to realize how close I had come to losing my life, and I saw very differently what mattered to me. What mattered were other people in my life. I was twenty-one. Every thought I’d had before that was: What ...more
how we seek to spend our time may depend on how much time we perceive ourselves to have.
Carstensen gave her hypothesis the impenetrable name “socioemotional selectivity theory.” The simpler way to say it is that perspective matters. She produced a series of experiments to test the idea. In one, she and her team studied a group of adult men ages twenty-three to sixty-six. Some of the men were healthy. But some were terminally ill with HIV/AIDS. The subjects were given a deck of cards with descriptions of people they might know, ranging in emotional closeness from family members to the author of a book they’d read, and they were asked to sort the cards according to how they would ...more
When, as the researchers put it, “life’s fragility is primed,” people’s goals and motives in their everyday lives shift completely. It’s perspective, not age, that matters most.
A colleague once told her, Wilson said, “We want autonomy for ourselves and safety for those we love.” That remains the main problem and paradox for the frail. “Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.”
And other research was consistent with this conclusion. In the early 1970s, the psychologists Judith Rodin and Ellen Langer performed an experiment in which they got a Connecticut nursing home to give each of its residents a plant. Half of them were assigned the job of watering their plant and attended a lecture on the benefits of taking on responsibilities in their lives. The other half had their plant watered for them and attended a lecture on how the staff was responsible for their well-being. After a year and a half, the group encouraged to take more responsibility—even for such a small ...more
Josiah Royce wrote a book with the title The Philosophy of Loyalty. Royce was not concerned with the trials of aging. But he was concerned with a puzzle that is fundamental to anyone contemplating his or her mortality. Royce wanted to understand why simply existing—why being merely housed and fed and safe and alive—seems empty and meaningless to us. What more is it that we need in order to feel that life is worthwhile? The answer, he believed, is that we all seek a cause beyond ourselves. This was, to him, an intrinsic human need. The cause could be large (family, country, principle) or small ...more
The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. If you don’t, mortality is only a horror. But if you do, it is not. Loyalty, said Royce, “solves the paradox of our ordinary existence by showing us outside of ourselves the cause which is to be served, and inside of ourselves the will which delights to do this service, and which is not thwarted but enriched and expressed in such service.” In more recent times, psychologists have used the term “transcendence” for a version of this idea. Above the level of self-actualization ...more
As our time winds down, we all seek comfort in simple pleasures—companionship, everyday routines, the taste of good food, the warmth of sunlight on our faces. We become less interested in the rewards of achieving and accumulating, and more interested in the rewards of simply being. Yet while we may feel less ambitious, we also become concerned for our legacy. And we have a deep need to identify purposes outside ourselves that make living feel meaningful and worthwhile.
Research has found that in units with fewer than twenty people there tends to be less anxiety and depression, more socializing and friendship, an increased sense of safety, and more interaction with staff—even in cases when residents have developed dementia. But
“Oh thank God I can go myself to the bathroom,” Makover told me. “You would think it’s nothing. You’re young. You’ll understand when you’re older, but the best thing in your life is when you can go yourself to the bathroom.”
And they are designed to pursue the idea that a life worth living can be created, in this case, by focusing on food, homemaking, and befriending others.
The terror of sickness and old age is not merely the terror of the losses one is forced to endure but also the terror of the isolation. As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world—to make choices and sustain connections to others according to their own priorities. In modern society, we have come to assume that debility and dependence rule out such autonomy. What I learned from Lou—and from Ruth ...more
People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete.
After a few days, they were even able to go out to a favorite restaurant; he wasn’t hungry, but they enjoyed just being there and the memories it stirred.
Patients entering hospice have had no less surprising results. Like many other people, I had believed that hospice care hastens death, because patients forgo hospital treatments and are allowed high-dose narcotics to combat pain. But multiple studies find otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or end-stage congestive heart failure. For the patients with breast cancer, prostate cancer, or colon cancer, the researchers found no difference in survival time between those who went into hospice and those who didn’t. And curiously, for some ...more
To understand La Crosse, Thompson said, you had to go back to 1991, when local medical leaders headed a systematic campaign to get medical people and patients to discuss end-of-life wishes. Within a few years, it became routine for all patients admitted to a hospital, nursing home, or assisted living facility to sit down with someone experienced in these conversations and complete a multiple-choice form that boiled down to four crucial questions. At this moment in your life, the form asked: 1. Do you want to be resuscitated if your heart stops? 2. Do you want aggressive treatments such as ...more
Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.
The first is the courage to confront the reality of mortality—the courage to seek out the truth of what is to be feared and what is to be hoped. Such courage is difficult enough. We have many reasons to shrink from it. But even more daunting is the second kind of courage—the courage to act on the truth we find. The problem is that the wise course is so frequently unclear. For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to ...more
What were her biggest fears and concerns? What goals were most important to her? What trade-offs was she willing to make, and what ones was she not?
“An inconsistency is built into the design of our minds,” Kahneman observes. “We have strong preferences about the duration of our experiences of pain and pleasure. We want pain to be brief and pleasure to last. But our memory … has evolved to represent the most intense moment of an episode of pain or pleasure (the peak) and the feelings when the episode was at its end. A memory that neglects duration will not serve our preference for long pleasure and short pains.”
Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?