Speaking Volumes: Dying Well

(Published in the Business Standard, October 2014)
Mahinder Watsa, and don’t know this, but they’re my secret role models for how to live a good life.

Dr Watsa, about 91, writes the “Ask the Sexpert” advice column and has probably spread more good across the land than any other Indian of the last five decades. Ho Kuo-chao can do five consecutive splits and martial art exhibitions at 90, while Ms Athill has published Somewhere Towards The End at 91, Life Class at 92, and Instead of a Book at 97.

I admire them, but that admiration is talismanic. Their lives – rich, full, relatively unscoured by the harsher ravages of old age – offer a promise that you can move into your eighties and nineties like moving house – the fittings might change, but you hope that the scenery and foundations will stay the same.

This is not realistic, as knows from his years of medical practice. People wear out fast. Aging is as wide and fluidly changing a river as adolescence and early adulthood, with as many distinct phases. But in most modern cultures, talking about death to the dying, or to those crossing the border that seals off middle from old age, is taboo.

“You look so young! So well!” people say, in denial of the obvious. Families turn to doctors for guidance, but Mr Gawande’s years of exploring this subject – from at least 2003 onwards in his essays and writings – have led him to believe that the medical establishment in the United States handles aging as badly as everyone else.

“Our textbooks had almost nothing on aging or frailty or dying,” Mr Gawande writes in Being Mortal, the fourth of his books exploring medicine, human behaviour, the sick and those who care for them. “How the process unfolds, how people experience the end of their lives, and how it affects those around them seemed beside the point.”

He suggests that we start with more clarity on how much there is to lose, or to protect. is structured as a series of inquiries into the human condition that weaves in and out of the lives, and deaths, of patients, closing with a poignant personal account of his father’s slow decline and eventual death. It is as important to die well as to live well, and perhaps one of the most interesting takeaways from Being Mortal is that with a shift in perspective, both are possible.

Given that death is one of the few certainties all humans have in common – not everybody tangoes, or zumbas, or plays kabbadi, but we’ll all be doing this dying business some day – it seems astonishing that we are still so bad at it. Mr Gawande does point out that today’s retirement homes and hospital care, however flawed, are infinitely better than the poorhouses of the West, or the hellish old age homes for the poor he describes in India.

Being Mortal is not written as a handbook to the aging and their families – Mr Gawande’s preferred style is analytical, open-ended, inquiring but rarely prescriptive – but it’s likely to be the most influential book on this subject for some years to come.

In chapter after chapter, he sifts the inevitable losses of aging from the losses and indignities that can actually be staved off: if more of the medical establishment were trained in geriatrics, if more people were in assisted living facilities and fewer in hospitals, if the focus was on maintaining independence and dignity for those we love rather than on just prolonging life.

The old do not want to yield control over their lives: in a rare moment of open anger, Mr Gawande writes, “You’d think people would have rebelled. You’d think we would have burned the nursing homes to the ground.”

The challenge, to his mind, is to imagine something better than the nursing home model, and also to start having the difficult conversations – with families, with doctors and the medical establishment – before people lose their independence, not after.

This is not a small challenge; while Mr Gawande’s model is based on the United States, where he lives and works, with some perspective on India provided by his many visits here, his journey to the family’s village and his caretaking for his father, the way in which India handles the elderly and the dying is being tested. Fewer than 10 per cent of Indians today, according to the Population Reference Bureau, have access to health insurance (public or private).

Though 91 per cent of Indians interviewed for a survey in 1991 said that caring for their elderly parents was a major priority, that had slipped to just 51 per cent of Indians surveyed in 2001 – a shift in attitude that is mirrored in the rising number of court cases that have to do with parents who’ve been abandoned, or left with no financial resources, or property by their children.

By 2050, India’s over-60 population is estimated to rise to about 34 per cent, according to the United Nations Population Division – roughly 323 million senior citizens, facing life without a strong supporting network of retirement communities, out of whom many will be dependent on others for their healthcare and their daily needs.

It can be hard to watch someone you love cross from the pleasures of aging – the maturity, perspective and sometimes the deeper understanding of one’s own passions and nature – over into the shadowlands of pain, dementia, confusion, or fatal illnesses.

But as Mr Gawande moves from analysing the medical world’s flawed responses to taking care of his father, he also sees the other side. There’s the almost intolerable dilemma his family is faced with, trying to understand an impenetrable thicket of numbers in order to make the best medical choices, but there is also grace. “Only now did I begin to recognize how understanding the finitude of one’s time could be a gift,” he writes. His father uses his time with more care, meets people important to him: “He found that in the narrow space of possibility that his awful tumour had left for him there was still room to live.”

Mr Gawande would like, as a doctor but also as a son and a human being, for that “narrow space” to be widened. Being Mortal is illuminating, alarming and immensely moving; it is also a manifesto, declaring that the way we see aging, illness and death must change. Many books promise to change the way people live, but this might actually change the way we die, too.






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