Sunday, 20. September 2015 by Todd Ellison
If you have elderly parents, here, to help you shepherd them through their last days, is a compilation of helpful quotes from Atul Gawande’s excellent book, Being Mortal: Medicine and What Matters in the End.
Many of us need help in even just opening a discussion with our aging parents about the important issues facing them in their final stages. As Gary Smalley has noted in Making Love Last Forever, experts have found that death and sex are two of the most difficult things to discuss.
Although Dr. Gawande doesn’t write from a Judeo-Christian perspective, he (aHarvard Medical School surgeon and professor) is effective at front running some thoughts on the complex issues that face the elderly. You as a believer can read these management strategies within the context of our faith in the resurrection—adding the very real hopes and eternal realities for your parents which are absent from this book’s presentation.
“Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone [and, we would add, the personal and loving sovereignty of Almighty God]. Medical science has given us remarkable power to push against those limits… But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.
“We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same:
• What is your understanding of the situation and its potential outcomes?
• What are your fears and what are your hopes?
• What are the trade-offs you are willing to make and not willing to make?
• And what is the course of action that best serves this understanding?” (p. 259)
This is a good way to think, at this juncture in life: “living for the best possible day today instead of sacrificing time now for time later.” (p. 229)
Dr. Gawande has come to believe that “whatever we can offer [a person who is in this situation], 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 [medical staff] forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.” (p. 260)
“At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality—the courage to seek out the truth of what is to be feared and what is to be hoped. Such courage is difficult enough. We have many reasons to shrink from it. But even more daunting is the second kind of courage—the courage to act on the truth we find. The problems is that the wise course is so frequently unclear. For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most.” (p. 232)
Dr. Gawande observes that the default setting of the medical establishment has been “You took the most aggressive treatment available.” On the other hand, “This [new] business of deliberating on your options—of figuring out your priorities and working with a doctor [him not as the Dictator or even as the Information-provider, but as a collaborator in interpreting the data and trying to fathom the unknowns] to match your treatment to them—[is] exhausting and complicate, particularly when you [aren’t able to ]...parse the unknowns and ambiguities. The pressure remains all in one direction, toward doing more, because the only mistake clinicians seem to fear is doing too little. Most have no appreciation that equally terrible mistakes are possible in the other direction—that doing too much could be no less devastating to a person’s life.” (p. 220)
Dr. Gawande summaries a study Daniel Kahneman reported in his book, Thinking, Fast and Slow, that found that there are two ways to evaluate experiences: how we apprehend them sequentially as they’re happening, and how we think of them afterwards. How we think about the afterwards, sticks with us a lot longer, and what we tend to recall are the most intense periods and the very last period of the experience. [Thus, how an experience—including a person’s life—ends, is crucial.] Kahneman called it the Peak-End rule. A key point here (pp. 238-239), is that “We have purposes larger than ourselves. Unlike your experiencing self—which is absorbed in the moment—your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. ... in stories, endings matter.” (pages 236-238)
“I am leery of suggesting the idea that endings are controllable. No one ever really has control. Physics and biology and accident have their way in our lives. But the point is that we are not helpless either. Courage is the strength to recognize both realities. We have room to act, to shape our stories, though as time goes on it is within narrower and narrower confines. A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.” (p. 243)
“Technological society has forgotten what scholars call the `dying role’ and its importance to people as life approaches its end. People want to share memories, pass on wisdoms and keepsakes, settle relationships, establish their legacies, make peace with God, and ensure that those who are left behind will be okay. They want to end their stories on their own terms [we would say, on the terms God dictates for them]. This role is…among life’s most important, for both the dying and those left behind.” (p. 249)