We are all mortal What is dear to us at the very end and how medicine can help here

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Author: Atul Gawande

Being Mortal: Medicine and What Matters at the End Atul Gawande 2014

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Old age as an experiment (mortal)

mortal: We love stories about 90-year-old marathoners and Kilimanjaro climbers. They maintain the illusion “Age is just a number in your passport!”. We do not want to accept reality as it is, and we are afraid to discuss the topics of aging and death. But Atul Gawande, a professor at Harvard Medical School, says it’s time to talk honestly about what awaits each of us at the end of life.

Why is old age so scary? “We have not yet learned to grow old,” says Atul Gawande. Throughout human history, the average life expectancy has been less than 30 years! Everything has changed in a couple of centuries. People have not yet adapted to the new reality, in which death from old age is a common thing, not a miracle.

We do not know how to live life with dignity to the very end, and we surrender to the power of doctors and medical technologies. But the doctors themselves have not yet mastered the new role. We are all participants in a large social experiment to turn old age and death into a medical problem. Atul Gawande believes that this experiment has failed: a person, even in the last days of life, needs not only care and security. 

Modern medicine is focused on maintaining life. The death of a patient for doctors is a loss, and its delay is again, even if the person “lives” in intensive care, connected to a ventilator.

Atul Gawande proposes to reconsider this approach and reminds us that death is not a defeat, but a part of life, its natural completion. Life is a story in which the end is as important as the beginning. We need to learn how to grow old and die, and doctors need to learn how to ease the last days of their patients’ lives with respect for their freedom and independence. 

This book will help you learn to empathize with the “quirks” of your parents and grandparents. You will be able to take better care of them by learning more about the physiology of aging and new approaches to caring for the elderly. And most importantly, you will think about how you want to see the end of your own story. What will be valuable at the end of your life just for you? 

How does our body age?

The Fading Process: Physiology

Doctors can work miracles: they replace blood vessels, joints, and valves. But medicine is still powerless against aging: sooner or later the human body is destroyed. Healthy eating and sports help slow down the aging process, but it is impossible to completely stop it. What awaits our body in old age? 

Teeth. Tooth enamel wears out with age, and blood flow to the pulp and roots of the teeth becomes less. The secretion of saliva decreases – and the gums are more likely to become inflamed. As we age, it becomes more difficult for us to chew – and we switch to soft foods that are higher in carbohydrates 1 . Carbohydrates cause fermentation processes and lead to the development of caries 2.

Danger: the sensitivity of the nerves becomes dull with age – and an elderly person often does not notice a toothache.

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Circulatory system. Blood vessels and heart valves accumulate calcium 3  and become hard. During heart surgery, surgeons feel how large vessels literally crunch under their fingers!

Danger: to maintain the same volume of blood flow through the narrowed blood vessels, the heart pumps up pressure. As a result, the walls of the heart thicken and are less able to bear the load. The older we are, the harder it is for us to do cardio.

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Muscle mass. At the age of 40, the process of gradual loss of muscle mass begins – and by the age of 80, a person loses up to half of the muscle mass.

Bone system. From the age of 50, bone density decreases by about one percent per year. The bones of older people appear translucent on x-rays. The inner surfaces of the joints wear out, and the joint space narrows – as a result, the bones rub against each other. 

Danger: in older people, fractures occur even when falling from a small height.

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Movement and touch. 

Due to swollen joints, the wrists lose their mobility – and it becomes more and more difficult for us to grasp movements. Due to the loss of motor neurons, we become less dexterous. Due to the wear of the receptors, tactile sensitivity decreases.

Danger: in old age, problems with fine motor skills appear. It is difficult for older people to use a regular mobile phone with small buttons and icons. 

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Brain. At 30, our brain weighs an average of 1.2 kg – and hardly fits in the cranium. By the age of 70, the loss of gray matter leads to the fact that the head becomes like a rattle: the brain moves freely inside the skull. 

Danger: Empty cavities between the brain and the cranium are the main cause of cerebral hemorrhages in the elderly. Even a small blow can lead to tragic consequences. Therefore, it is so important to protect grandparents from falling.

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Cognitive abilities. In older people, the frontal lobes (they are responsible for decision-making) and the hippocampus (responsible for memory) decrease. By age 85, 40% of people develop dementia. 

excretory system. With age, the mechanisms that remove waste gradually become unusable – and the remnants thicken into lipofuscin (thick pigment). The spots that you see on the skin of older people are caused by lipofuscin.

Danger: Lipofuscin often accumulates in the sweat glands. They cease to function normally – and any strong overheating leads to heat stroke. 

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Gerontology 

We cannot stop aging, but we can take control of this process and slow it down. Gerontologists are doctors who specialize in treating the elderly.

How can a gerontologist be useful:

  • Gerontologists study the list of drugs prescribed by other specialists in terms of their danger to the elderly. First of all, they are worried about the danger of losing balance and falling. 

Every year, about 350,000 Americans break their hips. 40% of them end up in a nursing home, and 20% permanently lose the ability to walk. 

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  • Gerontologists make sure that older people eat right and pay attention to warning signs that are invisible to other specialists. For example, an experienced gerontologist will always pay attention to the condition of the feet of an elderly person – according to them, he will determine the patient’s ability to bend down and take care of himself on his own. 
  • Gerontologists themselves or with the help of social workers check the safety of an elderly person’s home. Contrary to popular belief, the street is not the most dangerous place. In Russia, 76% of femoral neck injuries occur indoors. 

According to studies, older people who visit gerontologists are four times less likely to become disabled due to injuries and the progression of chronic diseases. They are 40% less likely to require home healthcare services. In addition, gerontologists help prevent the development of depression in older patients. 

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Old age: the right to freedom

The ethics of aging

For almost the entire history of mankind, those who are lucky enough to live to a ripe old age have not changed their lifestyle. It was more difficult for the elderly to deal with everyday worries, but there were always children, grandchildren, and great-grandchildren around who were ready to help. This approach to old age is still preserved in developing countries 4.

Atul Gawande: “Sitaram Gawande, my grandfather, at the age of 100, got up before dawn, and before going to bed he rode around his fields on a horse. If he lived not in India, but in the West, such behavior would be recognized as a dangerous whim – and the old man would be sent to a nursing home. 

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Older people in developed countries rarely have the opportunity to live their last days the way they want to. The family model has changed: the elderly have lost the authority of the head of the clan and can no longer count on round-the-clock assistance from children. Many survive alone or in the company of doctors in medical institutions.


The two main ethical questions about old age are:

  1. Should children give up their lives to care for aging parents?
  2. How do ensure the comfort and well-being of terminally ill or bedridden people?

As a rule, if people lose their self-care skills, they have two options: living in a nursing home or helping relatives.

Freedom or security?

Grandpa or grandma can no longer cook their own food and get dressed? “This is the problem of doctors!” For some reason, we decide. Moreover, all the elderly are sick with something. However, doctors have little to offer helpless old people or people who have lost their self-care skills. Doctors help delay death and alleviate suffering through surgery or pain medication. But by focusing on safety 5  and life extension, doctors forget what is truly valuable – respect for the human right to freedom and independence.

Relatives of infirm old people behave in exactly the same way as doctors. They restrict the freedom of parents, and grandparents “for their safety” – and do not notice how much suffering such a life brings them. 

Keren Wilson, gerontologist, founder of Assisted Living Concept: “Even children are allowed more than old people: at least they are allowed to swing and climb slides!”

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The worst is for those living in nursing homes. Their guests seem to be serving a sentence in prison for having lived to old age. Compulsory classes, strict daily routines, and rules are convenient for doctors and nurses, but oppress grandparents. In nursing homes, no one thinks that people’s lives should be filled with joy and meaning. 

Bill Thomas experiment

Bill Thomas, the founder of The Green House Project, took a job as the head physician at a nursing home. And he was horrified by how oppressive the atmosphere reigned there. Then he decided on an experiment – he obtained permission to have dogs, cats, and birds in a nursing home. His “crazy” idea brought amazing results. Those who had not left their rooms for a long time suddenly wanted to walk their dogs. Those who did not speak began to communicate. Over time, a kindergarten for the children of employees and circles for schoolchildren appeared in the nursing home. 

The researchers studied the results of the experiment and found that the cost of medicines in his nursing home was only 30% of the costs of the neighboring one. And the death rate decreased by 15%! Bill Thomas explained the results of the experiment by the need for something that is greater than the person himself. Taking care of animals and communicating with children brought not only joy to the residents of the nursing home, but also a sense of the meaning of life. Bill Thomas proved with his experiment that people get sick more and die faster if they feel loneliness, boredom, and suffer from helplessness.

Bill Thomas did not stop at reforming one nursing home and founded The Green House Project, a chain of boarding houses, turning his ideas of ideal old age into reality. In addition, he is actively involved in educational activities and seeks to reform the system of care for the elderly through the organization he founded, The Eden Alternative.

Bill Thomas Principles:

  • It is necessary to abandon the medical approach to caring for the elderly. Old people need pleasant company, comfort, and help in achieving their goals.
  • Our desires are capricious and fleeting. All people have a need for service, even if it is expressed in the care of a canary. Without devotion to something greater than ourselves, life becomes unbearable. 
  • Boarding houses for the elderly need to be equipped like ordinary houses. There should be living plants, familiar furniture, a common living room with a fireplace, and a kitchen.
  • It is important to encourage close social ties between boarding house guests, for example, having dinner together at a common table.
  • Boarding house employees should be friends of the guests rather than their caregivers. To do this, they need to be given more freedom in decision-making. In addition, The Green House Project employees have time to talk and play together with guests. 

Almost at home: Continuum Care principle

In Russia, it is still not customary to send parents to boarding houses for the elderly. First of all, even private boarding houses rarely look like a real house. However, in the US there are already boarding houses that combine the advantages of nursing homes (the ability to get medical help at any time) and the advantages of living at home (freedom and privacy). These boarding houses follow the principle of Continuum Care (“continuous care”), coined by Keren Wilston. 

A boarding house organized according to the principle of Continuum Care usually looks like this. 

Those who can do without constant help live in the home of the boarding house in apartments – alone or in couples. The space of the home part of the boarding house is divided into small compartments, each of which is designed for no more than 16 people.

Studies have shown that if more than 20 people live in a compartment, the level of anxiety and depression of the guests increases.

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Guests have the right to have pets if they can take care of them on their own. If possible, a school, a kindergarten, or at least school circles are located on the territory of the boarding house. The administration of the boarding house should stimulate communication between the guests and children: joint lessons, concerts, etc. The guests of the boarding house can work, for example, in the school library. And students can be involved in the patronage program for the elderly. Often such patronage ends in a touching friendship. 

Death: the right to rest

Just 100 years ago, doctors had no early diagnosis or ways to artificially prolong life. Therefore, the death of people was usually sudden: from several days to several weeks after the diagnosis was made. 

Today, thanks to modern medicine, death usually occurs after a long war with an incurable disease or the accumulated “symptoms” of old age. Both doctors and patients know that death is inevitable, but when it will come is unknown. Advances in medicine pose a new question for us: at what point is it time to stop trying to change what cannot be changed?

Ask yourself: Would you like to die in a hospital with a ventilator tube in your mouth and a catheter in your nose? Unconscious, unable to say goodbye to your loved ones? Or would you prefer to die the way people have done for thousands of years: at home, next to their loved ones?

Most of us want to die at home 6. However, when it comes to relatives, we often cling to an illusory hope and expect a miracle from doctors. In addition, we want to shift responsibility for decision-making to physicians. What could be worse than making the decision to disconnect your father or mother from medical devices on your own? 

From the point of view of medical ethics, a terminally ill patient has the right to help. But before providing this assistance, it is important to find out the priorities of the person. 7  Should you continue chemotherapy if you feel so bad after it that you can’t even walk? Should I do an operation if the risk of paralysis after it is 50%? 

Only the patient can answer these questions. But the doctor must inform the patient about the consequences of the choice and ask the right questions. The doctor’s task is to help a person realize what is valuable to him. For some, it is important to save strength for work, for others, the opportunity to eat chocolate and watch TV is enough. The individual’s priorities determine the treatment plan. They also determine the decision: whether to fight for life support in the hospital or spend the last days at home. 

Is it possible not to send a dying person to the hospital? Yes, but for this, both the person himself and his relatives must come to terms with the inevitability of death, and not console themselves with the illusion of magical healing. In addition, the relatives of the dying person will have to find answers to many new questions. What is the right way to behave around a dying person? How to help him? How to alleviate his suffering? Palliative medicine specialists have answers to these questions. 

What can palliative care do?

  • Relieve a person from pain, help to cope with nausea and other unpleasant symptoms. 
  • Provide 24/7 consultation with a doctor or nurse.
  • Provide a nurse who will help with both medical care and household issues.
  • Invite a psychologist or a priest.
  • Bring medical equipment to the person’s home.
  • Help the relatives of the deceased patient resolve issues related to ritual services.

The role of the dying

Palliative medicine has partly taken over the functions that have been a family and personal affair for thousands of years. Palliative care professionals are bringing back to people the ancient forgotten knowledge about the role of the dying and the role of those who are nearby. 

When a person realizes the reality of death, not sometime in decades, but in the coming days or months, his priorities change. Those who care for a person should remember this. Before death, it is important to share memories, give advice, and manage your property. The attention of the dying is on the here and now. The most valuable thing for a person at the end of life is simple joys. Delicious food, sun rays on the face, hugs of children and grandchildren, and the opportunity to say goodbye to them. 

Top 10 Thoughts

1. The process of aging and dying is a natural part of life, not a medical phenomenon.

2. People who are able to lead a full life at the age of 90 are the exception, not the rule. There is no need to feel shame and guilt about the fact that in old age you will need help. 

3. The professional task of doctors is not only to delay the death of the patient but also to do everything possible to preserve the quality of his life.

4. A terminally ill person has the right to know what is happening to his body and to the freedom to make decisions.

5. Even at death’s door, people have a need to serve and belong to something greater than themselves. If you take it away, life becomes unbearable. 

6. If you want a happy old age for yourself and your loved ones, look for ways to overcome boredom, feelings of loneliness, and helplessness. Simple things, like caring for a canary or house plants, fill life with joy and prolong it. 

7. Dying people have the right to rest and die in their homes without the intervention of doctors.

8. The most valuable thing at the end of life is simple joys. Provide a dying person with delicious food, walks, and communication with relatives.

9. If you are considering living in a nursing home or boarding house for yourself or your relatives, choose one that does not have strict rules. An ideal boarding house is like an ordinary house.

10. The sooner you think about old age, the more adjustments you can make. More than you think depends on you and your lifestyle. Sports and healthy eating will help make old age much more pleasant!

1 Dentist can determine the age of a person by the state of his teeth with an accuracy of 5 years!

2  After age 85, 40% of Americans have no teeth left.

3  With age, calcium seems to be washed out of the bones into soft tissues.

4  By 2050, the UN predicts an increase in the proportion of older people in the total population to 22%. And in developed countries, their number can reach 30-40%!

5  We want freedom for ourselves, but we demand security for relatives

6  It’s time to abandon the idea that the main need of a dying person is treated.

7  If a doctor sincerely wants to improve the life of a dying person, he needs to curb his impulse to intervene and make things right.

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