Being Mortal: Illness, Medicine and what Matters in the End

Gawande compares the end-of-life experiences of three different individuals in this section of the book. He checks back in with retired geriatrician Felix Silverstone and reports Silverstone’s decision to live at home with his wife even as her health was drastically failing. Quality of time versus quantity of time was the deciding factor and after his wife passes, Silverstone feels they made the right decision in not having her transferred to a ward that offered round-the-clock care that might’ve given her additional time but less connection or quality interaction. Gawande also reports on the end-of-lifedecision made by an eighty-three-year-old man named Harry Truman who refused to leave his home prior to the eruption of Mount Saint Helens in 1983. After watching the slow decline of Alice Hobson, Gawande wonders if Truman didn’t make the right decision. When Alice’s family decides it is best that she move into a nursing home in order for her health and their peace of mind, Alice becomes withdrawn and depressed. Deprived of the opportunity to dictate the own terms of her life, her will to live gradually disappears. He says of Alice’s experiences, “For Alice, it must have felt as if she had crossed into an alien land that she would never be allowed to leave. The border guards were friendly and cheerful enough […] but she just wanted to live a life on her own” (141). At last, she dies alone in her room without alerting any of the nursing staff to her pain or symptoms. Clearly, Gawande views this as a tragic way for her to go, as she was a person with a vibrant spirit despite the fragility of her physical circumstances. Though Gawande sympathizes with her in-laws’ desires to make sure Alice is well fed and looked after, he acknowledges that what we want for our loved ones is not always the same as what we want for ourselves. We may desire to keep our loved ones safe at any cost, minimizing any possible risk they could face, but in our own lives, we may be willing to see that eliminating all risks also likely eliminates many pleasures and freedoms.

Gawande is again critical of nursing homes in the case of Lou Sanders, who requires more care than his daughter, Shelly, can really manage on her own. Shelly has not fully considered the care her father will need in the end, but in this, Gawande thinks she is hardly alone: “As fewer of us are struck dead out of the blue, most of us will spend significant periods of our lives too reduced and debilitated to live independently. We do not like to think about this […][a]s a result, most of us are unprepared for it” (92).

Lou is first moved to an assisted-living facility but not one of the sort that was ideologically pioneered by Keren Brown Wilson in the 1980s. Brown wanted to design a space where elders could be more independent, even if they were dealing with illness or decreased mobility. According to Gawande:

Wilson believed she could create a place where people like Lou Sanders could live with freedom and autonomy no matter how physically limited they became. She thought that just because you are old and frail you shouldn’t have to submit to life in an asylum (140).

Wilson’s first “living center with assistance,” Park Place, was met with resistance. Yet Wilson was able to demonstrate that residents did well because they had an increased will to live compared to other elders whose every move was closed monitored in the name of prolonging and health.

In the 1990s, Wilson’s ideas were expanded by a doctor named Bill Thomas who rocked the boat even more by adding pets, plants and regular visits from children into the assisted living facility equation. In Bill Thomas own words: “Culture has tremendous inertia […] That’s why it’s culture. It works because it lasts. Culture strangles innovation in the crib” (187). His Eden Alternative became a hub of activity and was able to boast of success for its residents. His later model—small, communal style Green Houses—also offered seniors a chance to be engaged and independent and to prioritize enjoyment of life above constant nursing. It is in one of these homes that Lou Sanders eventually settles and is able to enjoy a semi-autonomous and communal life. Lou stays up late, eats as he pleases, debates politics and is free to be as social or reclusive as he wishes. He is a completely different man when he moves from a traditional nursing home to a more holistic-minded assisted-living community that prioritizes not just his physical well-being but his happiness and quality of life as well.