Being Mortal

gawandeI’ve just finished reading Being Mortal: What Matters in the End by Dr. Atul Gawande.

I had read his previous Complications about life as a surgeon several years ago, greatly impressed.

Both books have been highly praised, with the present book listed by the New York Times as among must reads of 2014.

As a surgeon at Massachusetts General Hospital, Gawande knows what he’s writing about.

And he writes well, often movingly, in layman’s language, of death scenarios with their accompanying challenges that need to be individualized, since we’re all different.

I suspect many readers will opt to avoid a seemingly morbid subject, but that’s a mistake, for   mortality knows no exceptions and our best approach is one that, through knowledge, provides us with options.

And Gawande, a writer for the prestigious New Yorker as well as a physician, delivers–deftly, compassionately, and always with eloquence, on a difficult subject.

Moreover, his book preeminently addresses the medical community, often committed to treatment paradigms that work against the patient’s welfare.

Physicians are trained to see themselves as enhancers of health and survival. They are not taught how to handle lingering illness devoid of remedy:

…within a few years, when I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality, and it did not take long to realize how unready I was to help them (3).

If your problem is fixable, we know just what to do.  But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering (8).

What’s the point, anyway, of continuing chemotherapy, radiation, and surgery in terminal cases when such methodologies may involve great risk and, often, increase duress?

When, in short, should doctors, not just patients, let go?

Patients cling to hope and doctors knowingly feed into this, when frequently no regimen can procure that miracle of restoring health and dignity.

Or as Gawande vividly makes clear in his allusion to Tolstoy’s powerful tale, The Death of Ivan Ilyitch:

What tormented Ivan Ilyitch most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result (2).

The ultimate challenge for physicians is to accept the restraints of biology and assist their patients to come to terms when that moment arrives

Otherwise, they can inflict considerable, even barbaric, suffering.

Doctors need to be patient-centered, addressing the patient’s best interests, and sometimes the greatest kindness entails being candid..

Ultimately, it’s about providing patients with options that preserve dignity, lessen suffering, and are in accord with the patient’s priorities.

We’ve made some progress in the now universal acceptance of Advanced Directives, though initially contested. But what about options for the terminal patient, still conscious, who lingers, often in great pain, and with perhaps even greater to come?

Gawande says that there are two dominating physician protocols: the one patronizing (this is what you should do); the other, informative (here are your scenarios).

Doctors do better when they ask the right questions of their patients in such contexts:

Whenever serious sickness or injury strikes and your body 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 or not willing to make? And what is the course of action that best serves this understanding? (259)

Palliative care, for example, may well be a better option to further surgery, chemotherapy and radiation when the outcome may make matters worse.

On the other hand, indulging patient fantasy may invoke “a prolonged and terrible death” (4).

Gawande carries out what he advocates. For me, his account of his father’s lingering passage into mortality is deeply moving, which I think many of us can identify with in our own wrestlings with the demise of those we love.

In addition to all of you, I wish every medical practitioner would read this book.

Death isn’t an enemy, but the natural order of things.

How much better it would be in our final moments to have someone like Gawande attending–a physician, with compassion, listening and helping us discern those best options that enhance our dignity and lessen our suffering.






Medicine’s Desertion of the Elderly

elderly“There’s no escaping the tragedy of life, which is that we are all aging from the day we are born,” writes Dr. Atul Gawande in his latest book, Being Mortal: Medicine and What Matters in the End.

Accordingly, I’ve reached that point in life when I wish I could consult with a geriatrician, or specialist on the aging process. Given that we are increasingly an aging population, you’d surmise it’s no problem finding one.

Count yourself lucky, if you do. And if you do, that you’ll get in.

I live in a city of 300,000, and home of a major university with a respected medical school and first class hospitals. Still, I couldn’t find one.

In fact, it may surprise you to learn that geriatricians are an increasingly rare breed.

Take the University of Minnesota, for instance. It recently shut down its Department of Geriatrics, despite its success in enhancing the quality of life for many seniors, reducing disability, both physical and mental, remarkably and, what’s more, the need for costly home services.

Unfortunately, treatment costs exceeded any savings (Gawande 45).

Other medical centers have followed suit, reducing or eliminating their geriatric services.

The medical establishment prides itself on fixing things, when for the elderly it’s management, not healing, that should define appropriate treatment.

Technology, however, is where the big bucks are and even Medicare, tailored for those 65 and over, falls short in paying for services specific to seniors.

Additionally, doctors often feel overwhelmed by elders coming to them with not one, but several ailments. Think hypertension, diabetes, asthma, arthritis, anemia, failing hearing and eyesight, etc.

in the meantime, most Americans will ultimately spend at least a year in a nursing home at considerable expense, which quality geriatric care might well have preempted.

I can’t help but think this sorry state of affairs is somehow related to our general disregard of older people in America, often the butt of jokes or derision.

One study indicates that 68% of the elderly believe that the public is indifferent to its older citizenry.

I don’t think it was always this way. I grew up in a time when we revered age. It’s still this way in countries like China, Japan, Korea and in Latin America. China recently enacted an Elderly Rights Law, mandating its citizens “never snub or neglect the elderly.”

In Korea, turning 60 and 70 are celebrated events.

In contrast, American culture–as in other Western countries–is youth-centric, with emphasis on independence.

Maybe it’s because, thanks to many of modern medicine’s achievements, there are too many of us now, with 20% of Americans projected to be over 65 in the next twenty years.

Currently, those over 65 constitute 26% of all doctor visits, 47% of all hospital stays, 34% of all prescriptions, and 90% of all nursing home stays (Institute of Medicine Report: Retooling for an Aging America).

Unfortunately, there are only 7,000 geriatricians, and that number is declining. As such, it’s only half of what’s needed to meet a growing need (

The elderly often have emotional as well as physical needs. Sadly, only 3% of psychologists devote the majority of their practice to those over 65.

Geriatric psychiatrists number only about 2,000 and, like geriatricians at large, that number is declining, according to the American Association for Geriatric Psychology.

How foolhardy all of this is, since the elderly constitute a minority most of us are destined to join.

Most of us don’t like to go there when it comes to thinking about growing old and confronting our mortality. Certainly, we don’t prepare ourselves for it very well, though it may be closing in on us sooner than we think.

The UN associates age 60 with elderly status.

In the USA, several states use the same criterion.

The bottom line is that sound medicine isn’t about money. It’s about compassion


Intimations of Mortality: Keats revisited

75px-JohnKeats1819_hiresI have always been fond of the poet, John Keats.  Maybe it’s because he seems to have been down on his luck so early in life and I just happen to be drawn to underdogs.  When he was just eight, he lost his father, who died falling from a horse.  At fourteen, his mother succumbed to TB, a disease that would prey upon the family, taking his brother, Tom, at nineteen and himself at barely twenty-five.  Meanwhile, lawyers consumed the family inheritance.

Keats always had a premonition of an early death, not surprising given the family history, but he didn’t know he was already ailing with TB when he became engaged to the girl next door, the coquettish Fanny Brawne in the fall of 1818.

The following year saw Keats penning in a six week period  the masterpieces for which he is now famous, poems like “Ode to a Nightingale,” “Ode to Melancholy,” “Ode to a Grecian Urn,” “Ode to Psyche,” and “La Belle Dame Sans Merci.”

On February 3, 1820, he coughed up blood in his bedroom and with his typical courage, exclaimed:  “I cannot be deceived in that color; that drop of blood is my death warrant. I must die.”

He would travel to Italy in a last desperate attempt to recover his health, only to die a few weeks later, attended by a lone friend.  Today he lies in Rome’s Protestant Cemetery.  Engraved on his tombstone is Keats’ chosen epitaph:  “Here lies one whose name was writ in water.”

I have always been attentive to Keats, visiting his last London Home, Wentworth Place,  in lovely Hampton Heath, and his last abode abroad, a small apartment in Rome adjacent to the Spanish Steps, Rome’s gathering place for throngs of young people from across the globe, presumably oblivious in the “mackerel crowded seas” (Yeats) to the drama enacted next door eclipsed by time.  I have also been to the cemetery, moved and reflecting on what might have been a different outcome with a better shuffling of the cards of fate.

He had aimed to write the best poetry of which he was capable and though dying so young, achieved a poetry the world still marvels at.   No poet, not even Shakespeare, Milton, or Wordsworth achieved such mastery at so young an age, laboring against illness, family misfortune, financial duress, rejection by the critics, and the anguish of loving a flirtatious Fanny, who often provoked his jealousy.

Of all the Romantics, he strikes me as the most poignant, ever aware of life’s brevity, or how temporality colors all, testing the significance of human assertion itself.  Paradox always characterizes his poetry and centers in the conflict of dream vs. reality.  Unlike many Romantics, Keats ultimately opts for truth in the interplay of mind and feeling.

I have been thinking a lot about him lately in conjunction with the cancer hoops I’ve had to jump through these pastt several months.  I had gone to an osteopath seeking relief for my back pain only to be told xrays showed a lump adjacent to the left clavicle, which might be cancerous.  A subsequent CT scan, though it showed no malignancy, revealed a large thyroid nodule, and I was again cautioned it might be cancer.  They found me a surgeon and in the meantime I had an ultrasound guided fine needle aspiration biopsy, which indicated another, smaller nodule on the left side of the thyroid.  The pathology report came back negative.

By then I met with my surgeon, who surprised me in light of the biopsy:  “I can’t guarantee you don’t have cancer.  FNAs have false negatives up to 20% of the time.”

While waiting for surgery five days away, I visited my dermatologist to check on a knee sore, which turned out inconsequential,  Alas, however, she found a black mole that might be melanoma, the most aggressive of cancers.  And so I had to go into surgery facing the double whammy of two cancers at separate sites, metastasis a distinct possibility.

The surgery went well.  The surgeon didn’t find cancer, so only a partial thyroidectomy was done, allowing me to perhaps avoid medication.  But I still hadn’t gotten the lab results on that black mole.  I had to actually call to get the report.  It was a precursor dysplasia nevus, which can turn into melanoma if not removed.  Even though benign, having dysplasia nevi increases your chances of getting melanoma, so it means constant vigil to catch early changes.

And so now you know why my thoughts have been so filled with Keats, though in this medically sophisticated age I’ve come upon some luck this dear poet was denied.  Living with premonition of his own demise, Keats wrote what may be my favorite poem, and I mean of any poet,

When I have fears that I may ease to be
Before my pen has gleaned my teeming brain,
Before high-pilèd books, in charactery,
Hold like rich garners the full ripened grain;
When I behold, upon the night’s starred face,
Huge cloudy symbols of a high romance,
And think that I may never live to trace
Their shadows with the magic hand of chance;
And when I feel, fair creature of an hour,
That I shall never look upon thee more,
Never have relish in the faery power
Of unreflecting love—then on the shore
Of the wide world I stand alone, and think
Till love and fame to nothingness do sink.

If you look at this poem carefully, you’ll find it fascinating in its astute organization; for example, the poem actually consists of one sentence, or subordinate clauses coalescing into a main clause at poem end.  In turn, this lends an accumulative buttressing of the persona’s earlier mention of his “piled up hopes.”.So many hopes, teeming high, but cut off by mortality.

The poem’s structure also features an antithesis between thinking and feeling in its three quatrains prior to the closing couplet in this Shakespearian sonnet.

Strikingly in consort with its theme, each quatrain moves us closer to the reality of death, with a progressive abstraction in the imagery with each succeeding quatrain:

Increasing abstraction:

rich garners

cloudy symbols

faery power


These quatrains also unleash inexorable transitory strictures of foreclosure, feeding into the “nothingness” of the closing couplet in which death renders all human dreams, whether of love or fame, insignificant.

Increasing transitoriness:


one night

one hour

The poem’s imagery is likewise supportive of the theme, with an imagery cluster featuring darkness, shadows and clouds,

For the poet, death represents closure on love and artistry and fame.  I remember reading one of Keats’s letters in which he called death “the great divorcer.”

The truth is that ultimately we all get our ticket punched; but for Keats, he was so young,  talented, and in love.  Sometimes life can be cruelly unfair.  Nonetheless, with the quiet courage that always characterized him, he accepted his fate.

There are lessons here for all of us: to pile up the nows, knowing the temporality that governs us all; to live quietly and simply, centered in the right values; to discern those issues that matter;  above all, to love amply those around us.


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