Being Mortal: Medicine and What Matters in the End

by Atul Gawande

death is not a subject that his doctors, friends, or family can countenance. That is what causes him his most profound pain.

He was pursuing little more than a fantasy at the risk of a prolonged and terrible death—which was precisely what he got.

We could never bring ourselves to discuss the larger truth about his condition or the ultimate limits of our capabilities, let alone what might matter most to him as he neared the end of his life. If he was pursuing a delusion, so were we.

I have the writer’s and scientist’s faith, however, that by pulling back the veil and peering in close, a person can make sense of what is most confusing or strange or disturbing.

If you cannot, without assistance, use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk—the eight “Activities of Daily Living”—then you lack the capacity for basic physical independence.

It was clear that the family would ensure my grandfather could continue to live as he desired.

in my grandfather’s premodern world, how he wanted to live was his choice, and the family’s role was to make it possible.

There is arguably no better time in history to be old.

Our reverence for independence takes no account of the reality of what happens in life: sooner or later, independence will become impossible.

If independence is what we live for, what do we do when it can no longer be sustained?

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.

As we age, it’s as if the calcium seeps out of our skeletons and into our tissues.

The peak output of the heart therefore decreases steadily from the age of thirty.

By age eighty, one has lost between a quarter and a half of one’s muscle weight.

The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized.

Processing speeds start decreasing well before age forty

By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia.

for most of our hundred-thousand-year existence—all but the past couple of hundred years—the average life span of human beings has been thirty years or less.

only 3 percent of how long you’ll live, compared with the average, is explained by your parents’ longevity;

We wear down until we can’t wear down anymore.

the amount of light reaching the retina of a healthy sixty-year-old is one-third that of a twenty-year-old.

we blind ourselves to the opportunities that exist to change the individual experience of aging for the better.

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 body’s decline creeps like a vine. Day to day, the changes can be imperceptible. You adapt. Then something happens that finally makes it clear that things are no longer the same.

When the prevailing fantasy is that we can be ageless, the geriatrician’s uncomfortable demand is that we accept we are not.

The very old are the highest-risk drivers on the road.

As fewer of us are struck dead out of the blue, most of us will spend significant periods of our lives too reduced and debilitated to live independently.

He felt they knew each other, and loved each other, more than at any time in their nearly seventy years together.

Somewhere along the seven-mile drive between the house she’d given up on Greencastle Street and Longwood House, her life fundamentally changed in ways she did not want but could do nothing about.

To Alice, Longwood House was a mere facsimile of home. And having a place that genuinely feels like your home can seem as essential to a person as water to a fish.

This place where half of us will typically spend a year or more of our lives was never truly made for us.

The trouble was that she expected more from life than safety.

it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.

Today, assisted living is regarded as something of an intermediate station between independent living and life in a nursing home.

Wilson decided to try spelling out on paper an alternative that would let frail elderly people maintain as much control over their care as possible, instead of having to let their care control them.

AT THE CENTER of Wilson’s work was an attempt to solve a deceptively simple puzzle: what makes life worth living when we are old and frail and unable to care for ourselves?

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.

Far from growing unhappier, people reported more positive emotions as they aged.

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

as your horizons contract—when you see the future ahead of you as finite and uncertain—your focus shifts to the here and now, to everyday pleasures and the people closest to you.

Assisted living most often became a mere layover on the way from independent living to a nursing home.

Wilson pointed out angrily that even children are permitted to take more risks than the elderly. They at least get to have swings and jungle gyms.

“Dressing somebody is easier than letting them dress themselves. It takes less time. It’s less aggravation.”

The tasks come to matter more than the people.

assisted living isn’t really built for the sake of older people so much as for the sake of their children.

“We want autonomy for ourselves and safety for those we love.”

“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.”

“It’s the rare child who is able to think, ‘Is this place what Mom would want or like or need?’ It’s more like they’re seeing it through their own lens.” The child asks, “Is this a place I would be comfortable leaving Mom?”

Out of love and devotion, Shelley felt she had no choice but to put him where he dreaded.