Being Mortal

In 1991, a man named Bill Thomas begins a job as medical director of Chase Memorial Nursing Home in New Berlin, New York. Until then Thomas worked as an emergency physician at a nearby hospital, and he took the job as a chance to do something different. With fresh eyes, Thomas sees how depressing the nursing home is. At first, he tries to find a doctor’s solution, examining the residents and investigating their medications to bolster their spirits.

Soon, Thomas realizes that he needs to try something totally different. He knows the value of an independent and self-sufficient life. He wants to put more life into the home by adding plants, animals, and children to the residents’ lives. He lays out a plan to apply for a small New York State grant for innovations. He wants to attack the “Three Plagues of nursing home” life: boredom, loneliness, and helplessness. He suggests two dogs, four cats, and 100 birds. They win the grant and all the regulatory waivers needed to follow through on it.

Thomas and others bring in the animals and the garden, and staff members bring in their children. Seeing the animals, the residents offer to help care for them. They establish feeding shifts for the animals and walking schedules for the dogs. The residents’ engagement with the animals not only makes them happier, but it also helps the staff monitor their sharpness as residents give daily reports on the animals.

Researchers study the effects of this experiment over two years and find that the number of prescriptions required per resident fell to half of that of a control nursing home—particularly drugs for agitation. Thomas posits that this is because of the fundamental human need for a reason to live. Even something as small as a plant to take care of makes people more active and alert.

Thomas recalls meeting a man named Mr. L., who was admitted to the nursing home after a suspected suicide attempt. He gave up walking and refused to eat. But when he accepted a pair of parakeets, he started to perk up, giving him something to watch, companionship, and the chance to take care of something. He began eating, dressing, and getting out. He took the dog for a walk. Three months later, he moved out and back to his home—Thomas is convinced the program saved his life.

In 1908, Harvard philosopher Josiah Royce wrote a book questioning why being merely housed and fed and safe and alive seems empty and meaningless. He concluded that we all seek a cause (big or small) beyond ourselves: family, country, a building project, or the care of a pet. Royce calls this “loyalty,” the opposite of “individualism.” The individualist puts his own interest first, and loyalty to something other than themselves seems strange. But he argues that human beings need loyalty, because our own desires are fleeting and often difficult to fully satisfy.

Gawande supports Royce’s philosophy, noting that people care deeply what happens to the world after they die. As people’s time winds down, they become less ambitious but more concerned about legacy and the need to identify purposes outside themselves that make living meaningful. The problem with medicine and its institutions is that they have no view about what makes life significant. They concentrate on health and safety, but not “sustenance of the soul.” And yet these institutions define people’s last days. Both Bill Thomas and Keren Wilson wanted to help people in a state of dependence pursue meaningful existence.

Gawande explores other places that have tried to change the model, like NewBridge, a residence in the Boston suburbs. It is built not with shared apartments along endless corridors, but as houses for sixteen people, with private rooms built around common living areas. Research has found that units with fewer than 20 people have less anxiety and depression, more socializing and friendship, greater safety, and more interaction with staff. And it avoids the feel of a clinical setting, helping people bond and join in each other’s activities.

One day, Gawande interviews one NewBridge resident, Rhoda Makover. At 99, she has frequent falls and is nearly blind from retinal degeneration. But the staff understands how important walking is to her health and her mental well-being, so they allow her to continue. A few years earlier she lived alone and was happy. But then when she started falling, she moved into a nursing home. She was there for a year before moving to NewBridge and said there was no comparison. NewBridge also shares its grounds with a private school for kindergarten through eighth grade, and residents can work as tutors and librarians.

Another place, Peter Sanborn Place, was built in 1983 and had 73 units for independent, low-income elderly people. As residents aged, Jacquie Carson, the director, knew she needed more accommodations for them. She brought in physical therapists and organized nurses. But officially, it’s still just a low-income housing unit. Carson often battles the medical system, working with ambulance services and hospitals so that the place is consulted about care for residents. But to her, it’s most important to help the residents stay in their homes.

Making lives meaningful in old age is new, and there aren’t any standard solutions yet. Gawande interviews Ruth Beckett, a Sanborn resident. She explained that her son Wayne has cerebral palsy; he can handle basic aspects of life, but he needs structure and supervision. When Sanborn opened, he became his first resident. Three decades later, when a fall put Ruth in a nursing home, Carson worked out how to take Ruth in so she could be with her son. Jacquie hopes to build more units, but she faces lack of funding and bureaucracy.

Gawande finds many places trying to change the traditional nursing home model. While these places often look extremely different from one another, the people in charge of them are committed to a single goal—maintaining people’s autonomy. There are different kinds of autonomy: one is living completely independently and free of limitation. But this is only a means to an end, as freedom is not a measure of worth in a person’s life. There is a second sense of autonomy: the freedom to be the author one’s own life. The battle of being mortal is the battle to maintain a connection to who you are or who you want to be. Professionals and institutions should not make this battle harder in the name of safety.

Lou is soon to go to a nursing home when Shelley hears about a new place opening: the Leonard Florence Center. Lou is impressed from the first tour, as all the rooms are single—something normally unheard of in nursing homes. It also looks like a home, rather than a hospital. This is in part thanks to Bill Thomas, who wanted to build a home for the elderly from the ground up—one that looked like a nursing home to the government, but which felt like a home to the residents. He called it a “Green House.” Not long afterward, a foundation he worked with launched the National Green House Replication Initiative, which constructed more than 150 Green Houses—including the Leonard Florence Center.

All Green Houses are small and communal, with no more than 12 people. The residences are warm and homey, and the residents determine their own schedules. Residents like Lou work together with the caregivers, each of whom focuses on just a few residents. Each caregiver cooks, cleans, and most importantly, provides companionship. Lou connects with the other residents, but he also values his time alone. Sitting with Lou and talking in the Green House, Gawande thinks that this is the first time that he does not fear reaching this phase of life. While Lou’s mind and body are slowly deteriorating, he is still able to live in a way that makes him feel he has a place in the world.