Mind Matters — Being Mortal

None of us know when we will die, but we can’t deny that it is inevitable. Even tax evaders can’t avoid mortality. Atul Gawande, M.D., in his book, Being Mortal: Medicine and What Matters in the End, invites us to reflect on the process of aging and death.

Death can be instantaneous, sudden, but usually it isn’t. More than likely, we face the aging of our elders, our parents and then come to the brink of our own mortality in a process over time, rather than in a nano-second. When I was fifty, I took care of my parents in their dying. Now I am almost seventy and wonder about my own end of life issues as I work with people older than I. Some are residents in assisted living; others are still living independently. Yet we all want the same thing: autonomy in our decision making, and a sense of aliveness to continue.

Gawande articulates in his writing what I have observed first hand working with an aging population., particularly residents in assisted living. These folks have enough capital to afford such a safe and comfortable place, and even at that, the situation is far from optimal. Yes, in general, the nursing staff is caring, competent and compassionate. Yet the operative words here are “nursing” and “staff.” Nursing implies a medical model where the hallmark activity is the dispensing of medicines in a timely manner. “Staff” conveys the regimentation necessary to maintain institutional structure. Sure, we all need structure. However, often times the institution supersedes the uniqueness and importance of the individual.

Gawande describes how the typical “nursing home” operates: “efficiency … [demands] that the nursing aide staff have the residents ready for the activity coordination staff, who … [keep] them out of the rooms for the cleaning staff, et cetera.” (p. 143)

In his research, however, Gawande found an alternate model of care, called the “Green House” where control no longer resided with facility managers but with the “frontline caregivers.” These caregivers would focus on just a few residents and are thereby able to have more contact with the residents, becoming more like companions. My hunch is that the stereotypical assisted living model could incorporate the Green House idea simply by increasing the ratio of aides to residents.

Perhaps the most compelling message Gawande purveys is that medicine does not have all the answers, especially when it comes to aging and death. Sometimes the medical model attempts to prolong life to the detriment of living a life. And in the interest of “patient safety,” elderly residents are constrained and restricted from making choices.

I remember one woman resident of a facility who loved to go outside and walk. Given her dementia, she was considered an “elopement” risk. Eventually, she was confined to the locked unit—windowless, airless, but it had a TV! So there she sat with others like her. Was she safe? Yes, but to what end? Unfortunately, the facility where she resided had no outdoor gated walks where she could be outside, yet contained. When I would walk through her unit and call her name she would always look up and give a big smile and say “Hello, dearie!” Was her will to run waning due to her dementia or to the medications that blunted her? To keep her “safe?” We know, with the medical model, how to keep people “safe” but we don’t know with that model how to let them really live.

Gawande invites us to rethink how we treat our elderly—who, if we’re “lucky”—will eventually be ourselves.