Being Mortal

Dr. Atul Gawande recalls that, in medical school, he and his classmates rarely talked about mortality and how people experience death. The students and professors largely saw the purpose of medical school as teaching them how to save lives, not to tending to people’s demise.

The only time Gawande discussed mortality was in a weekly seminar called “Patient-Doctor,” in which they read Tolstoy’s The Death of Ivan Ilyich. In the story, Ilyich is 45 years old, and one day, he falls off a stepladder and develops a pain in his side. The pain grows worse, and he becomes unable to work. Doctors aren’t able to figure out exactly what’s wrong, and their remedies do nothing. Tolstoy writes that what bothers Ivan Ilyich the most is that everyone believes he is ill, not that he is dying. But he wants to be comforted as someone at the end of his life.

The medical students in the class believed that the failure in Ivan Ilyich’s case belonged to the doctors: they couldn’t properly diagnose him, and if they could, honesty and kindness and comfort would have followed. The students were more worried about having the proper knowledge, not about sympathizing. And yet when Gawande went out into the world, he found himself completely unprepared to help patients confront the possibility of death.

Gawande flashes back to his time as a junior resident. At the time, he began writing essays, including one about Joseph Lazaroff—a city administrator in his 60s who is suffering from a metastatic prostate cancer. Lazaroff loses weight, his body fills with fluid, and one day he can’t control his right leg or bowels. The doctors find that his cancer has spread to his spine. It can’t be cured, but they hope it can be treated. They provide him with two options: comfort care or a relatively risky surgery.

No matter what, Lazaroff probably has a few months to live. Recovery would be difficult, and the operation could worsen and shorten his life. But Lazaroff still wants the operation. Lazaroff’s wife died on a ventilator in intensive care a few years earlier, and at the time he told his son he didn’t want anything like that to happen to him. But now he doesn’t want to feel like he is giving up.

Gawande believes Lazaroff’s choice is a bad one, not because of the dangers of the operation, but because the operation cannot give Lazaroff the life that he really wants. The operation is a technical success, but Lazaroff never recovers from the procedure: he develops respiratory failure, an infection, and blood clots. Two weeks later, Gawande takes Lazaroff off the ventilator at Lazaroff’s son’s request.

A decade later, reviewing the story, Gawande is amazed at how much the doctors avoided talking about the choice honestly. They explained the dangers of the treatment options, but they never communicated the reality of the disease: it could not be cured, and Lazaroff would never return to the life he used to have. In this way, they didn’t do much better (and may have done worse) than the doctors in Ivan Ilyich.

Modern science allows people to live longer and better than at any other time, but it also turns aging and dying into medical processes. In 1945, most deaths occurred in the home. But by the 1980s, only 17 percent did. The experience of aging and death has shifted to hospitals and nursing homes. When Gawande became a doctor, he did so to explore how medicine could pull people through difficult illnesses and injuries. He wasn’t prepared to see medicine’s limits.

Death is not a failure: death is normal and inevitable. It’s sometimes difficult for doctors to comprehend this, particularly because they are in a profession meant to fix problems. But with unfixable problems, doctors rarely know what to do, and this has caused “extraordinary suffering.”

The book is about the modern experience of mortality in the United States, and how the current medical systems are failing. The last days of people’s lives are given over to treatments that addle their brains and sap their energies for the smallest hope of a benefit. They are spent in nursing homes, where people are cut off from all the things that mattered to them in life. Gawande aims to explore how the experience of dying has changed and how it might be improved.