Gawande spends much of the book providing historical context for modern end-of-life care in the United States, including the rise of hospitals and nursing homes, and the impact of Social Security and pensions on aging. By providing this background, the book explores how social, economic, and technological progress has enabled people to live much longer lives. However, this progress has also created a new host of problems surrounding people’s ability to lead satisfying lives in their old age. Ultimately, Gawande calls for a reform of medical care for the elderly, retirement homes, and nursing homes, arguing that these changes will help people live more meaningful and financially sustainable lives in their old age, not just longer ones.
Due to advancements in medicine, humans have greatly increased life expectancy, but the medical field doesn’t have doctors who are equipped to care for the increasing number of elderly people. Life expectancy was under 50 in 1900, climbed to more than 60 by the 1930s, and today, it is in the late 70s in the United States thanks to improvements in medicine. In 30 years, there will be as many 80 year-olds as 5-year-olds. No longer are people debilitated by simple infections or common conditions like high blood pressure, showing the clear benefits of medical advancements. At the same time, medicine has been slow to account for the care of the elderly, which has only become more vital as more people reach old age. While the elderly population is growing rapidly, the number of geriatricians (doctors who handle the care of elderly people specifically) in the United States has fallen 25% between 1996 and 2010. Partly this has to do with money, as incomes among geriatricians are among the lowest in medicine. But partly, this has to do with the fact that a lot of doctors don’t like taking care of the elderly. In one year, fewer than 300 doctors will complete geriatrics training in the United States, which isn’t enough to replace the geriatricians going into retirement. Because of this, Gawande argues that it is necessary to overhaul this type of care. To meet the growing demand, the existing geriatricians should train primary care doctors in caring for the very old.
While increased financial independence has allowed people to retire in their sixties, the greatly increased lifespan of older Americans has put a major strain on American financial institutions. With the passing of the Social Security Act of 1935, elderly people became more financially independent. These factors led to the development of retirement communities, as retirees looked for places that would help them live out their “leisure years.” This was a major improvement—prior to this, many elderly people worked until they were completely physically debilitated, and if they weren’t wealthy and didn’t have family to stay with, they lived in poorhouses. Yet at the same time, retirement communities have created their own problems, particularly now that people are living significantly longer. People are putting less money aside in savings for old age now than they have at any time since the Great Depression, but because people are living longer, the cost of retiring is going up as people spend more years of their lives in retirement homes. While the average income for people over 80 is $15,000, the average rent for a retirement community is $32,000 a year, while entry fees are $60,000 to $120,000 on top of that. Because of the cost of retirement and lack of income, more than half of elderly people in the U.S. have to go on government assistance to afford it. Thus, these communities may have given people places to live, but greater reform is necessary to help people save for this phase of their lives.
Initially, nursing homes were initially meant to ease hospitals’ burdens and provide better care for the elderly, but as the institutions have evolved, they’ve fallen short of this goal. After World War II, medical advancements in antibiotics, other drugs, and surgery led to a proliferation of hospitals, which could now cure more ailments like high blood pressure, kidney failure, and bacterial infections. And because old people became more independent rather than living with family, they often wound up in hospitals for the last phase of their lives due to their many ailments. Beds filled up, and the hospitals lobbied the government for relief. In 1954, lawmakers provided funding to help hospitals build separate units for patients needing an extended period of recovery—which became the modern nursing home. And so, Gawande argues, the systems we’ve devised for the elderly are inadequate because they are “almost always designed to solve some other problem” (hospital overcrowding, for instance) and don’t actually take into account the elderly’s needs. Thus, Being Mortal suggests that nursing homes need to be reformed in order to be more than simply a place to live and receive basic care.
With new medicine and economic progress, many people’s lives have improved—but new problems have arisen, too. As Gawande writes, “Making lives meaningful in old age is new. It therefore requires more imagination and invention than making them merely safe does.” Being Mortal thus sheds a light on the need to reform the U.S.’s institutions to make people’s newfound old age financially sustainable, technologically possible, and psychologically meaningful.
Related Themes from Other Texts
The Evolution of End-of-Life Care ThemeTracker
The Evolution of End-of-Life Care Quotes in Being Mortal
You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.
The fascinating thing is that, over time, it doesn’t seem that the elderly have been especially sorry to see the children go. Historians find that the elderly of the industrial era did not suffer economically and were not unhappy to be left on their own. Instead, with growing economies, a shift in the pattern of property ownership occurred. As children departed home for opportunities elsewhere, parents who lived long lives found they could rent or even sell their land instead of handing it down. Rising incomes, and then pension systems, enabled more and more people to accumulate savings and property, allowing them to maintain economic control of their lives in old age and freeing them from the need to work until death or total disability. The radical concept of “retirement” started to take shape.
The progress of medicine and public health has been an incredible boon—people get to live longer, healthier, more productive lives than ever before. Yet traveling along these altered paths, we regard living in the downhill stretches with a kind of embarrassment. We need help, often for long periods of time, and regard that as a weakness rather than as the new normal and expected state of affairs. We’re always trotting out some story of a ninety-seven-year-old who runs marathons, as if such cases were not miracles of biological luck but reasonable expectations for all. Then, when our bodies fail to live up to this fantasy, we feel as if we somehow have something to apologize for.
Equally worrying, and far less recognized, medicine has been slow to confront the very changes that it has been responsible for—or to apply the knowledge we have about how to make old age better. Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010. Applications to training programs in adult primary care medicine have plummeted, while fields like plastic surgery and radiology receive applications in record numbers. Partly this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, a lot of doctors don’t like taking care of the elderly.
But hospitals couldn’t solve the debilities of chronic illness and advancing age, and they began to fill up with people who had nowhere to go. The hospitals lobbied the government for help, and in 1954 lawmakers provided funding to enable them to build separate custodial units for patients needing an extended period of “recovery.” That was the beginning of the modern nursing home. They were never created to help people facing dependency in old age. They were created to clear out hospital beds—which is why they were called “nursing” homes.
This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals—from freeing up hospital beds to taking burdens off families’ hands to coping with poverty among the elderly—but never the goal that matters to the people who reside in them: how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore.
Taking care of a debilitated, elderly person in our medicalized era is an overwhelming combination of the technological and the custodial. […] The burdens for today’s caregiver have actually increased from what they would have been a century ago. Shelley had become a round-the-clock concierge/chauffeur/schedule manager/medication-and-technology troubleshooter, in addition to cook/maid/attendant, not to mention income earner. Last-minute cancellations by health aides and changes in medical appointments played havoc with her performance at work, and everything played havoc with her emotions at home. Just to take an overnight trip with her family, she had to hire someone to stay with Lou, and even then a crisis would scuttle the plans. One time, she went on a Caribbean vacation with her husband and kids but had to return after just three days. Lou needed her.
“He agreed, with the indifference of a person who knows he will soon be gone,” Thomas said. But he began to change. “The changes were subtle at first. Mr. L. would position himself in bed so that he could watch the activities of his new charges.” He began to advise the staff who came to care for his birds about what they liked and how they were doing. The birds were drawing him out. For Thomas, it was the perfect demonstration of his theory about what living things provide. In place of boredom, they offer spontaneity. In place of loneliness, they offer companionship. In place of helplessness, they offer a chance to take care of another being. […] Three months later, he moved out and back into his home. Thomas is convinced the program saved his life.
Certainly, suffering at the end of life is sometimes unavoidable and unbearable, and helping people end their misery may be necessary. Given the opportunity I would support laws to provide these kinds of prescriptions to people. About half don’t even use their prescription. They are reassured just to know they have this control if they need it. But we damage entire societies if we let providing this capability divert us from improving the lives of the ill. Assisted living is far harder than assisted death, but its possibilities are far greater, as well.
If to be human is to be limited, then the role of caring professions and institutions—from surgeons to nursing homes—ought to be aiding people in their struggle with those limits. Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life. When we forget that, the suffering we inflict can be barbaric. When we remember it, the good we do can be breathtaking.
