Being Mortal

For most of history, death was a common, ever-present possibility. For most people, life would continue nicely until illness hit and people would deteriorate quickly—like Gawande’s grandmother Gopikabai Gawande, who died of malaria before she was 30. But now, public health measures and advances in science have reduced the mortality of infection, traumatic injuries, childbirth, heart attacks, strokes, and many other conditions.

Even people with incurable cancers can undergo treatment, bringing symptoms under control for much longer. Although people still deteriorate rapidly, the point at which the bottom drops out occurs much later. Even if doctors can’t stave off damage, they can stave off death. When people enter hospitals looking terrible, doctors can provide them with care that allows them to recover some ground. On the whole, however, medical progress has allowed large numbers of people to get a full life span and die essentially of old age, as people’s bodily systems fail over time.

While medicine and public health have allowed for great progress, they have changed the way we think about old age. When people need help, they see this as weakness rather than a normal state of affairs. While one 97-year-old may be able to run a marathon, this is not the norm, and it is unrealistic to believe in this fantasy. This progress also makes it difficult for doctors to know how to treat people in old age unless there is a discrete problem to fix.

Teeth are a good example of the natural way in which people age. While dental care can help avert tooth loss, old age gets in the way: the gums become enflamed, the roots of the teeth atrophy, and problems like arthritis make it difficult to brush and floss. The ability to chew food declines, and people shift to soft food, which are higher in carbs and more likely to cause cavities. By 85, almost 40 percent of people have no teeth.

While bones and teeth soften, the rest of the body hardens. Blood vessels, joints, and muscles pick up calcium deposits as bones wear away, and they stiffen. To maintain the same volume of blood flow through these blood vessels, the heart generates increased pressure, and more than half of people develop hypertension by 65. The heart muscle thickens, and muscle elsewhere thins and deteriorates.

All of these processes are normal. While they can be slowed, they cannot be stopped. Lung capacity decreases, bowels slow, brains shrink—losing particularly the areas devoted to memory, judgment, and planning. Why we age is a subject of debate: the classical view is that aging happens because of wear and tear, but the newest view suggests that aging is genetically programmed, which is why most people prior to the past few hundred years died before 30. Thus, aging today is a very unnatural process.

Nonetheless, genetic inheritance has little influence on longevity, and so wear and tear may explain more than expected. Leonid Gavrilov, a researcher at the University of Chicago, argues that human beings fail the way complex systems fail: randomly and gradually. Humans are designed with many backup systems and redundancies, allowing us to function even as damage accumulates. But as defects increase, there is a point in time where one more defect is enough to impair the whole system.

People choose to avoid the subject of aging and death, and as a result, few societies have come to terms with the increasing number of old people. While the retirement age is still 65, people over this age approach close to 20 percent of the population, and few people give thought to how they will live in these later years. Additionally, these days people are putting aside less in savings for old age than they have at any time since the Great Depression.

At the same time, there is a shortage of geriatricians in the medical profession, because it pays less compared to other jobs in medicine. Additionally, many people dislike taking care of the elderly, who often have a multitude of problems and can be difficult to treat. There’s nothing glamorous about taking care of high blood pressure, diabetes, or arthritis. One cannot cure these things—but one can manage them.

One morning, Gawande sits in on some patient visits in the geriatric clinic in his hospital with the chief geriatrician, Juergen Bludau. The doctor’s first patient, an 85-year-old woman named Jean Gavrilles, has lower back and leg pain. She also has bad arthritis, high blood pressure, and glaucoma. Lately, she’s had trouble controlling her bowels, and she recently had surgery for colon cancer. Gavrilles lives alone, and she takes care of herself capably.

Bludau asks about Jean’s day in great detail before examining her. She is in good condition for her age, but she faces everything from arthritis and incontinence to what might be metastatic colon cancer. Gawande thinks that the doctor could focus on the most potentially life threatening problem (the cancer) or the problem that bothers Jean the most (the back pain). But instead, the doctor spends most of the time looking at her feet, because often older people cannot bend down to reach their feet, and this suggests real danger and neglect.

Bludau informs Jean that she’s doing impressively well, and the most serious threat she faces is falling. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people with all three have almost a 100 percent chance of falling in a given year, and Jean has at least two. She has poor balance, as indicated by her neglected feet. And she’s on five medications, some of which have the side effect of dizziness. But she doesn’t have muscle weakness, and Bludau wants her to preserve her strength.

Later, Bludau tells Gawande that his job is to support quality of life: both freedom from disease, and the retention of enough function for active engagement in the world. He switches some of Jean’s medications to avoid dizziness, recommends a podiatrist for her feet, and also suggests that she eat a snack during the day to keep her muscles strong. Almost a year later, Gawande follows up with Jean: she is eating better and still lives comfortably, without a single fall.

When Alice Hobson began to fall frequently, Gawande didn’t understand how much of an alarm bell that was. She then got into a car accident, mistaking the brake for the accelerator. Soon after, two men scammed her out of $7,000 when they did yard work for her and cornered her in her house until she wrote them a check. The men were eventually caught and convicted, but the whole process indicated that Alice was growing increasingly vulnerable, and Jim suggested they look at retirement homes.

Medicine can determine whether a person’s decline is steep or more gradual. One study at the University of Minnesota focused on men and women over 70 who were living independently but had a high risk of becoming disabled. Half of them were randomly assigned to a team of geriatricians, while the other half were simply asked to see their usual physician. Within 18 months, 10 percent of each group died. But the patients who saw the geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services.

The geriatrics team simplified medications, controlled arthritis, and promoted overall health. But a few months after the study was published, the university closed the geriatrics division, because the services were too costly. This is a pattern all over the United States, which is why many doctors are choosing not to go into geriatrics. But the financial problems are indicative of a deeper reality: society does not prioritize doctors who bolster resilience in old age.

Gawande meets Felix Silverstone, a national leader in geriatrics for five decades, when the man is 87 years old. Felix can feel his own mind and body wearing down. He worked until he was 82, at which point he had to retire to take care of his wife, Bella, who became almost completely blind. They moved into a retirement community for people over 75, and when they needed to, they could upgrade to assisted living.

The retirement community is expensive, which is true of retirement communities generally. More than half of the elderly living in long-term care facilities spend their entire savings and have to go on government assistance to afford it. Ultimately, many Americans go to nursing homes, which Felix hopes to avoid. He is most concerned about the changes in his brain, as he feels his cognitive ability slipping. Sometimes, he feels he is depressed.

What buoys Felix is a sense of purpose. He improves the health care services at his retirement home and forms a journal-reading club for retirement physicians. Most importantly, he cares for Bella. He knows that he has to be honest with himself about his progress, because if his health fails, he won’t be any help to her.

One evening, Gawande goes to dinner with Felix and Bella. Felix helps Bella sit and orders for her, as she can’t read the menu. When the food arrives, Felix tells Bella where the food is on her plate by the hands of a clock. She almost chokes on her food, and then he almost chokes as well. Gawande is amazed that Felix can still remain independent, care for Bella, and do his research.

Felix has managed his old age well—particularly in finding a skilled geriatrician to help him. While there won’t be enough geriatricians to replace the retiring ones, geriatrics professor Chad Boult posits that the best strategy is to direct geriatricians to train primary care doctors and nurses to deal with the very old. This will help improve their care overall.

One day Gawande accompanies Felix on a drive to run an errand. Gawande is admittedly nervous to be in the car: the very old are the highest-risk drivers on the road. Felix is a capable driver, and he’s happy to be on the road. But Gawande knows that someday soon, Felix will have to give up his keys.