{"id":4777,"date":"2015-09-21T23:00:27","date_gmt":"2015-09-21T23:00:27","guid":{"rendered":"http:\/\/steelwagstaff.com\/?p=4777"},"modified":"2016-11-01T16:07:59","modified_gmt":"2016-11-01T16:07:59","slug":"atul-gawandes-being-mortal","status":"publish","type":"post","link":"https:\/\/steelwagstaff.info\/wordpress\/atul-gawandes-being-mortal\/","title":{"rendered":"Atul Gawande&#8217;s Being Mortal"},"content":{"rendered":"<p>I recently went to Salt Lake City for a family reunion. Among the relatives I saw was my only surviving grandparent, who is now 89 years old. He&#8217;s literally my oldest friend, and the oldest living human being that I know right now. His health is slowly deteriorating (he lost his driver&#8217;s license recently&#8211;which turns out to be not such a bad thing for the public at large, especially since, according to Gawande \u201cThe risk of a fatal car crash with a driver who\u2019s eighty-five or older is more than three times higher than it is with a teenage driver. The very old are the highest-risk drivers on the road\u201d), and I don&#8217;t know how many more trips I&#8217;ll have to see him. Since his mortality was on my mind, I thought it was a perfect time to read a book that I&#8217;ve been excited to learn with and think through ever since I first heard about it: Atul Gawande&#8217;s <cite><a href=\"http:\/\/atulgawande.com\/book\/being-mortal\/\" target=\"_blank\">Being Mortal: Medicine and What Matters in the End<\/a><\/cite>.<\/p>\n<p>The book itself is about the limits of medicine, how we care for our elderly, and\u00a0how we die, with explorations of alternative paths towards medical treatment of the elderly, hospice care for the terminally ill, and alternatives to medicalized nursing care for the elderly who require assistance or care in performing daily tasks. It was well worth reading, and grew my affection considerably for geriatricians,\u00a0hospice care, and most of all for <a href=\"http:\/\/changingaging.org\/about\/\" target=\"_blank\">Bill Thomas<\/a>&#8216;s notion of what a nursing home might be\u00a0and <a href=\"http:\/\/www.ccliving.com\/about-ccl\/management-team\/keren-brown-wilson.html\" target=\"_blank\">Keren Brown Wilson<\/a>&#8216;s original ideals of assisted living. After finishing the book, I felt very clear that I wanted first to develop an advanced directive to specify my own desires at the end of my life, and then to have more frequent and more earnest conversations about aging and death with my parents and with my wife. I hope that I will be able to accept the limits of my own life, and that I&#8217;ll be able to feel (and abide) by the ideas espoused by Ezekiel Emanuel in his recent essay &#8220;<a href=\"http:\/\/www.theatlantic.com\/magazine\/archive\/2014\/10\/why-i-hope-to-die-at-75\/379329\/\">Why I Hope to Die at 75<\/a>,&#8221; particularly around medical procedures which would prolong, but not enrich, my life.<\/p>\n<p>Some meaningful passages from Gawande&#8217;s book:<\/p>\n<h2>From the Introduction:<\/h2>\n<blockquote><p>[W]hat strikes me most is &#8230;\u00a0how much we all avoided talking honestly about the choice before him [they had been treating a man dying of painful cancer]. We had no difficulty explaining the specific dangers of various treatment options, but we never really touched on the reality of his disease. His oncologists, radiation therapists, surgeons, and other doctors had all seen him through months of treatments for a problem that they knew could not be cured. We could never bring ourselves to discuss the larger truth about his condition or the ultimate limits of our capabilities, let alone what might matter most to him as he neared the end of his life. If he was pursuing a delusion, so were we. Here he was in the hospital, partially paralyzed from a cancer that had spread throughout his body. The chances that he could return to anything like the life he had even a few weeks earlier were zero. But admitting this and helping him cope with it seemed beyond us. We offered no acknowledgment or comfort or guidance. We just had another treatment he could undergo. Maybe something very good would result.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver\u2019s chance of benefit. They are spent in institutions\u2014nursing homes and intensive care units\u2014where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.<\/p><\/blockquote>\n<h2>From Chapter 1: The Independent Self<\/h2>\n<blockquote><p>[Demographers] have also noticed that, during the eighteenth century, in the United States and Europe, the direction of our lies changed. Whereas today people often understate their age to census takers, studies of past censuses have revealed that they used to overstate it. The dignity of old age was something to which everyone aspired.<\/p>\n<p>But age no longer has the value of rarity. In America, in 1790, people aged sixty-five or older constituted less than 2 percent of the population; today, they are 14 percent. In Germany, Italy, and Japan, they exceed 20 percent. China is now the first country on earth with more than 100 million elderly people.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>There is arguably no better time in history to be old. The lines of power between the generations have been renegotiated, and not in the way it is sometimes believed. The aged did not lose status and control so much as share it. Modernization did not demote the elderly. It demoted the family. It gave people\u2014the young and the old\u2014a way of life with more liberty and control, including the liberty to be less beholden to other generations. The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It\u2019s been replaced by veneration of the independent self.<\/p>\n<p>There remains one\u00a0problem with this way of living. Our reverence for independence takes no account of the reality of what happens in life: sooner or later, independence will become impossible. Serious illness or infirmity will strike. It is as inevitable as sunset. And then a new question arises: If independence is what we live for, what do we do when it can no longer be sustained?<\/p><\/blockquote>\n<h2><span style=\"line-height: 1.5;\">From Chapter 2: Things Fall Apart<\/span><\/h2>\n<blockquote><p>[T]he advances of modern medicine have given us two revolutions: we\u2019ve undergone a biological transformation of the course of our lives and also a cultural transformation of how we think about that course.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>[A]t the age of thirty, the brain is a three-pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room. That\u2019s why elderly people &#8230;\u00a0are so much more prone to cerebral bleeding after a blow to the head\u2014the brain actually rattles around inside. The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized. As a consequence, memory and the ability to gather and weigh multiple ideas\u2014to multitask\u2014peaks in midlife and then gradually declines. Processing speeds start decreasing well before age forty (which may be why mathematicians and physicists commonly do their best work in their youth). By age eighty-five, working memory and judgment are sufficiently impaired that 40 percent of us have textbook dementia.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>[F]or most of our hundred-thousand-year existence\u2014all but the past couple of hundred years\u2014the average life span of human beings has been thirty years or less. (Research suggests that subjects of the Roman Empire had an average life expectancy of twenty-eight years.) The natural course was to die before old age. Indeed, for most of history, death was a risk at every age of life and had no obvious connection with aging, at all. As Montaigne wrote, observing late-sixteenth-century life, \u201cTo die of age is a rare, singular, and extraordinary death, and so much less natural than others: it is the last and extremest kind of dying.\u201d So today, with our average life span in much of the world climbing past eighty years, we are already oddities living well beyond our appointed time. When we study aging what we are trying to understand is not so much a natural process as an unnatural one.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>[M]edicine has been slow to confront the very changes that it has been responsible for\u2014or to apply the knowledge we have about how to make old age better. Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010. Applications to training programs in adult primary care medicine have plummeted, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money\u2014incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, a lot of doctors don\u2019t like taking care of the elderly.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>What geriatricians do\u2014bolster our resilience in old age, our capacity to weather what comes\u2014is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition,\u00a0medications, and living situations. And it requires each of us to contemplate the unfixables in our life, the decline we will unavoidably face, in order to make the small changes necessary to reshape it. When the prevailing fantasy is that we can be ageless, the geriatrician\u2019s uncomfortable demand is that we accept we are not.<\/p><\/blockquote>\n<h2>From Chapter 3: Dependence<\/h2>\n<blockquote><p>For most of our species\u2019 existence, people were fundamentally on their own with the sufferings of their body. They depended on nature and chance and the ministry of family and religion. Medicine was just another a tool you could try, no different from a healing ritual or a family remedy and no more effective. But as medicine became more powerful, the modern hospital brought a different idea. Here was a place where you could go saying, \u201cCure me.\u201d You checked in and gave over every part of your life to doctors and nurses: what you wore, what you ate, what went into the different parts of your body and when. It wasn\u2019t always pleasant, but, for a rapidly expanding range of problems, it produced unprecedented results. Hospitals learned how to eliminate infections, remove cancerous tumors, reconstruct shattered bones. They could fix hernias and heart valves and hemorrhaging stomach ulcers. They became the normal place for people to go with their bodily troubles, including the elderly.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>In almost no [nursing home] does anyone sit down with you and try to figure out what living a life really means to you under the circumstances, let alone help you make a home where that life becomes possible.<\/p>\n<p>This is the consequence of a society that faces the final phase of the human life cycle by trying not to think about it. We end up with institutions that address any number of societal goals\u2014from freeing up hospital beds to taking burdens off families\u2019 hands to coping with poverty among the elderly\u2014but never the goal that matters to the people who reside in them: how to make life worth living when we\u2019re weak and frail and can\u2019t fend for ourselves anymore.<\/p><\/blockquote>\n<h2>From Chapter 4:\u00a0Assistance<\/h2>\n<blockquote><p>Your chances of avoiding the nursing home are directly related to the number of children you have, and, according to what little research has been done, having at least one daughter seems to be crucial to the amount of help you will receive.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<p>On Stanford psychologist <a href=\"http:\/\/longevity3.stanford.edu\/people\/laura-carstensen\/\" target=\"_blank\">Laura Carstensen<\/a>&#8216;s socioemotional selectivity theory:<\/p>\n<blockquote><p>[H]ow we seek to spend our time may depend on how much time we perceive ourselves to have. When you are young and healthy, you believe you will live forever. You do not worry about losing any of your capabilities. People tell you \u201cthe world is your oyster,\u201d \u201cthe sky is the limit,\u201d and so on. And you are willing to delay gratification\u2014to invest years, for example, in gaining skills and resources for a brighter future. You seek to plug into bigger streams of knowledge and information. You widen your networks of friends and connections, instead of hanging out with your mother. When horizons are measured in decades, which might as well be infinity to human beings, you most desire all that stuff at the top of Maslow\u2019s pyramid\u2014achievement, creativity, and other attributes of \u201cself-actualization.\u201d But as your horizons contract\u2014when you see the future ahead of you as finite and uncertain\u2014your focus shifts to the here and now, to everyday pleasures and the people closest to you.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>Assisted living most often became a mere layover on the way from independent living to a nursing home. It became part of the now widespread idea of a \u201ccontinuum of care,\u201d which sounds perfectly nice and logical but manages to perpetuate conditions that treat the elderly like preschool children. Concern about safety and lawsuits increasingly limited what people could have in their assisted living apartments, mandated what activities they were expected to participate in, and defined ever more stringent move-out conditions that would trigger \u201cdischarge\u201d to a nursing facility. The language of medicine, with its priorities of safety and survival, was taking over, again. [Keren] Wilson pointed out angrily that even children are permitted to take more risks than the elderly. They at least get to have swings and jungle gyms.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>A colleague once told her, Wilson said, \u201cWe want autonomy for ourselves and safety for those we love.\u201d That remains the main problem and paradox for the frail. \u201cMany of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self. &#8230; \u00a0It\u2019s the rare child who is able to think, \u2018Is this place what Mom would want or like or need?\u2019 It\u2019s more like they\u2019re seeing it through their own lens.\u201d The child asks, \u201cIs this a place I would be comfortable leaving Mom?\u201d<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>In the absence of &#8230; a vast extended family constantly on hand to let [them]\u00a0make [their] own choices\u2014our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.<\/p><\/blockquote>\n<h2>From Chapter 5:\u00a0A Better Life<\/h2>\n<blockquote><p>Consider the fact that we care deeply about what happens to the world after we die. If self-interest were the primary source of meaning in life, then it wouldn\u2019t matter to people if an hour after their death everyone they know were to be wiped from the face of the earth. Yet it matters greatly to most people. We feel that such an occurrence would make our lives meaningless.<\/p>\n<p>The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. If you don&#8217;t, mortality is only a horror.<\/p><\/blockquote>\n<p>C.f. sections 2 and 3 of George Oppen&#8217;s &#8220;<a href=\"http:\/\/www.poetryfoundation.org\/poem\/175675\" target=\"_blank\">The Image of the Engine<\/a>&#8221;<\/p>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant. The problem is that they have had almost no view at all. Medicine\u2019s focus is narrow. Medical professionals concentrate on repair of health, not sustenance of the soul. Yet\u2014and this is the painful paradox\u2014we have decided that they should be the ones who largely define how we live in our waning days. For more than half a century now, we have treated the trials of sickness, aging,\u00a0and mortality as medical concerns. It\u2019s been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs.<\/p>\n<p>That experiment has failed.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>Our lives are inherently dependent on others and subject to forces and circumstances well beyond our control. Having more freedom seems better than having less. But to what end? The amount of freedom you have in your life is not the measure of the worth of your life. Just as safety is an empty and even self-defeating goal to live for, so ultimately is autonomy&#8230;<\/p>\n<p>The battle of being mortal is the battle to maintain the integrity of one\u2019s life\u2014to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse. But we have at last entered an era in which an increasing number of them believe their job is not to confine people\u2019s choices, in the name of safety, but to expand them, in the name of living a worthwhile life.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>The terror of sickness and old age is not merely the terror of the losses one is forced to endure but also the terror of the isolation. As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world\u2014to make choices and sustain connections to others according to their own priorities. In modern society, we have come to assume that debility and dependence rule out such autonomy. What I learned from Lou\u2014and from Ruth Barrett, Anne Braveman, Rita Kahn, and lots of others\u2014was that it is very much possible.<\/p><\/blockquote>\n<h2>From Chapter 6: Letting Go<\/h2>\n<p>Sarah Creed explains the fundamental values of hospice care:<\/p>\n<blockquote><p>The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in the priorities. In ordinary medicine, the goal is to extend life. We\u2019ll sacrifice the quality of your existence now\u2014by performing surgery, providing chemotherapy, putting you in intensive care\u2014for the chance of gaining time later. Hospice deploys nurses, doctors, chaplains, and social workers to help people with a fatal illness have the fullest possible lives right now\u2014much as nursing home reformers deploy staff to help people with severe disabilities. In terminal illness that means focusing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as feasible, or getting out with family once in a while\u2014not on whether Cox\u2019s life would be longer or shorter.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>A study led by the sociologist Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive and then followed the patients. Sixty-three percent of doctors overestimated their patient\u2019s survival time. Just 17 percent underestimated it. The average estimate was 530 percent too high. And the better the doctors knew their patients, the more likely they were to err.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>When there is no way of knowing exactly how long our skeins will run\u2014and when we imagine ourselves to have much more time than we do\u2014our every impulse is to fight, to die with chemo in our veins or a tube in our throats or fresh sutures in our flesh. The fact that we may be shortening or worsening the time we have left hardly seems to register. We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can\u2019t eat: there\u2019s always something. We want these choices. But that doesn\u2019t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something. Fix Something. Is there any way out of this?<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>Two-thirds of the terminal cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did have discussions were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive care unit. Most of them enrolled in hospice. They suffered less, were physically more capable, and were better able, for a longer period, to interact with others. In addition, six months after these patients died, their family members were markedly less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish. &#8230; \u00a0[T]hose who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives\u2014and they lived 25 percent longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality. If end-of-life discussions were an experimental drug, the FDA would approve it.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>Our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come\u2014and escape a warehoused oblivion that few really want.<\/p><\/blockquote>\n<h2>From Chapter 7:\u00a0Hard Conversations<\/h2>\n<blockquote><p>This business of deliberating on your options\u2014of figuring out your priorities and working with a doctor to match your treatment to them\u2014was exhausting and complicated, particularly when you didn\u2019t have an expert ready to help you 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\u2014that doing too much could be no less devastating to a person\u2019s life.<\/p><\/blockquote>\n<h2>From Chapter 8:\u00a0Courage<\/h2>\n<blockquote><p>At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality\u2014the 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\u2014the courage to act on the truth we find. The problem 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\u2019ve come to see, is more fundamental than that. One has to decide whether one\u2019s fears or one\u2019s hopes are what should matter most.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>Studies in numerous settings have confirmed <a href=\"https:\/\/en.wikipedia.org\/wiki\/Peak%E2%80%93end_rule\" target=\"_blank\">the Peak-End rule<\/a> and our neglect of duration of suffering. Research has also shown that the phenomenon applies just as readily to the way people rate pleasurable experiences. Everyone knows the experience of watching sports when a team, having performed beautifully for nearly the entire game, blows it in the end. We feel that the ending ruins the whole experience. Yet there\u2019s a contradiction at the root of that judgment. The experiencing self had whole hours of pleasure and just a moment of displeasure, but the remembering self sees no pleasure at all. &#8230;\u00a0[W]e also recognize that the experiencing self should not be ignored. The peak and the ending are not the only things that count. In favoring the moment of intense joy over steady happiness, the remembering self is hardly always wise.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>I am leery\u00a0of suggesting the idea that endings are controllable. No one ever really has control. Physics and biology and accident ultimately 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 the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one\u2019s 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\u2019s lives.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>We stop the healthy from committing suicide because we recognize that their psychic suffering is often temporary. We believe that, with help, the remembering self will later see matters differently than the experiencing self\u2014and indeed only a minority of people saved from suicide make a repeated attempt; the vast majority eventually report being glad to be alive. But for the terminally ill who face suffering that we know will increase, only the stonehearted can be unsympathetic. &#8230; Given the opportunity, I would support laws to provide these kinds of prescriptions\u00a0[fatal\u00a0doses of drugs for the terminally ill]. About half don\u2019t even use their prescription. They are reassured just to know they have this control if they need it. But we damage entire societies if we let providing this capability divert us from improving the lives of the ill. Assisted living is far harder than assisted death, but its possibilities are far greater, as well.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>Technological society has forgotten what scholars call the \u201cdying role\u201d 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. This role is, observers argue, among life\u2019s most important, for both the dying and those left behind. And if it is, the way we deny people this role, out of obtuseness and neglect, is cause for everlasting shame. Over and over, we in medicine inflict deep gouges at the end of people\u2019s lives and then stand oblivious to the harm done.<\/p><\/blockquote>\n<h2>From the Epilogue<\/h2>\n<blockquote><p>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. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. 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. &#8230; If to be human is to be limited, then the role of caring professions and institutions\u2014from surgeons to nursing homes\u2014ought to be aiding people in their struggle with those limits. Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person\u2019s life. When we forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.<\/p><\/blockquote>\n<ul>\n<li>\u00a0 \u00a0 * \u00a0 \u00a0 *<\/li>\n<\/ul>\n<blockquote><p>As an adult watching [my father]\u00a0in his final years, I also saw how to come to terms with limits that couldn\u2019t simply be wished away. When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that there are times when the cost of pushing exceeds its value. Helping my father through the struggle to define that moment was simultaneously among the most painful and most privileged experiences of my life.<\/p>\n<p>Part of the way my father handled the limits he faced was by looking at them without illusion. Though his circumstances sometimes got him down, he never pretended they were better than they were. He always understood that life is short and one\u2019s place in the world is small. But he also saw himself as a link in a chain of history. Floating on that swollen river, I could not help sensing the hands of the many generations connected across time. In bringing us there, my father had helped us see that\u00a0he was part of a story going back thousands of years\u2014and so were we.<\/p><\/blockquote>\n<p><small>Featured image\u00a0by <a href=\"http:\/\/www.flickr.com\/photos\/37547255@N08\/5664261318\" target=\"_blank\">Fylkesarkivet i Sogn og Fjordane<\/a> <\/small><\/p>\n","protected":false},"excerpt":{"rendered":"<p>I recently went to Salt Lake City for a family reunion. Among the relatives I saw was my only surviving grandparent, who is now 89 years old. He&#8217;s literally my oldest friend, and the oldest living human being that I know right now. His health is slowly deteriorating (he lost his driver&#8217;s license recently&#8211;which turns [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":5022,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_themeisle_gutenberg_block_has_review":false,"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":true,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":"","jetpack_publicize_message":"I've written a new post on Atul Gawande's excellent book Being Mortal","jetpack_publicize_feature_enabled":true,"jetpack_social_post_already_shared":true,"jetpack_social_options":{"image_generator_settings":{"template":"highway","default_image_id":0,"font":"","enabled":false},"version":2}},"categories":[47,19],"tags":[3,30,223,8],"class_list":["post-4777","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-reading-notes","category-reading","tag-death","tag-medicine","tag-philosophy","tag-writing"],"featured_image_src":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2016\/11\/5664261318_7d5db1cda9_b.jpg?resize=600%2C400&ssl=1","author_info":{"display_name":"Steel Wagstaff","author_link":"https:\/\/steelwagstaff.info\/wordpress\/author\/steel\/"},"jetpack_publicize_connections":[],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2016\/11\/5664261318_7d5db1cda9_b.jpg?fit=900%2C685&ssl=1","featured_image_src_square":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2016\/11\/5664261318_7d5db1cda9_b.jpg?resize=600%2C600&ssl=1","jetpack_shortlink":"https:\/\/wp.me\/pd6z5D-1f3","jetpack-related-posts":[{"id":4871,"url":"https:\/\/steelwagstaff.info\/wordpress\/how-to-write-a-dare-letter\/","url_meta":{"origin":4777,"position":0},"title":"How To Write a &#8220;DARE&#8221; Letter","author":"Steel Wagstaff","date":"June 26, 2012","format":false,"excerpt":"So there are \"kids, don't do drugs\" lectures, and then there are \"kids, don't do drugs\" lectures (like Tolstoy's \"Why Do Men Stupefy Themselves\"--an absolute classic). I grew up Mormon, which meant that the Word of Wisdom (Section 89 of the Doctrine and Covenants, a book of LDS scripture) formed\u2026","rel":"","context":"In &quot;Lessons from Oppen's Letters&quot;","block_context":{"text":"Lessons from Oppen's Letters","link":"https:\/\/steelwagstaff.info\/wordpress\/category\/lessons-from-oppens-letters\/"},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":1102,"url":"https:\/\/steelwagstaff.info\/wordpress\/george-oppen\/","url_meta":{"origin":4777,"position":1},"title":"George Oppen","author":"Steel Wagstaff","date":"June 15, 2012","format":false,"excerpt":"I will try to keep this post brief, and being brief, it will certainly fail to capture the depth and breadth of my admiration for George Oppen as a poet and a human being, but I feel the need to essay--to make an attempt. I've just finished, this evening, a\u2026","rel":"","context":"In &quot;Favorite People&quot;","block_context":{"text":"Favorite People","link":"https:\/\/steelwagstaff.info\/wordpress\/category\/favorite-people\/"},"img":{"alt_text":"","src":"https:\/\/steelwagstaff.files.wordpress.com\/2012\/06\/img_0457.jpg?w=350&h=200&crop=1","width":350,"height":200},"classes":[]},{"id":4861,"url":"https:\/\/steelwagstaff.info\/wordpress\/happy-geeks-a-story-by-steel-wagstaff-age-16-2\/","url_meta":{"origin":4777,"position":2},"title":"&#8220;Happy Geeks&#8221;: A Story by Steel Wagstaff, age 16","author":"Steel Wagstaff","date":"June 17, 2011","format":false,"excerpt":"This past week I started teaching an introductory college composition course for a group of incoming UW student athletes. It's a small group, just 14 male students, and most of the group are football players. For their second writing assignment, I gave them an essay that I wrote was I\u2026","rel":"","context":"In &quot;Blog&quot;","block_context":{"text":"Blog","link":"https:\/\/steelwagstaff.info\/wordpress\/category\/blog\/"},"img":{"alt_text":"","src":"","width":0,"height":0},"classes":[]},{"id":4766,"url":"https:\/\/steelwagstaff.info\/wordpress\/belle-waring\/","url_meta":{"origin":4777,"position":3},"title":"Belle Waring","author":"Steel Wagstaff","date":"September 9, 2015","format":false,"excerpt":"I can't remember exactly when I first read Belle Waring's poems. It probably would have been at least a decade ago, and I do remember that it was one of her poems about nursing, maybe even \"It Was My First Nursing Job\". What I remember most was feeling that I\u2026","rel":"","context":"In &quot;Favorite People&quot;","block_context":{"text":"Favorite People","link":"https:\/\/steelwagstaff.info\/wordpress\/category\/favorite-people\/"},"img":{"alt_text":"Group of nurses, Base Hospital #45","src":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2015\/09\/3005145811_932a4645f8_o.jpg?fit=695%2C448&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2015\/09\/3005145811_932a4645f8_o.jpg?fit=695%2C448&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2015\/09\/3005145811_932a4645f8_o.jpg?fit=695%2C448&ssl=1&resize=525%2C300 1.5x"},"classes":[]},{"id":4719,"url":"https:\/\/steelwagstaff.info\/wordpress\/ignazio-silones-fontamara\/","url_meta":{"origin":4777,"position":4},"title":"Ignazio Silone&#8217;s Fontamara","author":"Steel Wagstaff","date":"July 9, 2015","format":false,"excerpt":"At the recommendation of my friend Spencer, I recently began reading the Italian novelist Ignazio Silone's\u00a0The Abruzzio Trilogy, beginning with his 1933 novel\u00a0Fontamara. It is an extraordinary bit of social-realist inflected anti-fascist satire, and I found myself quickly devouring it and eager to begin the next book in the series.\u2026","rel":"","context":"In &quot;Reading Notes&quot;","block_context":{"text":"Reading Notes","link":"https:\/\/steelwagstaff.info\/wordpress\/category\/reading-notes\/"},"img":{"alt_text":"Cover of the 1st edition of Ignazio Silone's Fontamara","src":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2016\/11\/Fontamara_1st_edition.jpg?fit=400%2C336&ssl=1&resize=350%2C200","width":350,"height":200},"classes":[]},{"id":6188,"url":"https:\/\/steelwagstaff.info\/wordpress\/my-april-2017-reading\/","url_meta":{"origin":4777,"position":5},"title":"My April 2017 Reading","author":"Steel Wagstaff","date":"May 1, 2017","format":false,"excerpt":"Books My leisure reading of books slowed down a bit in April, as I continued getting sucked into lots more longform than I had intended and, on a happier note, did a lot more reading for my dissertation (good news!!!). Here's some of what I read last month for pleasure.\u2026","rel":"","context":"In &quot;What I'm Reading&quot;","block_context":{"text":"What I'm Reading","link":"https:\/\/steelwagstaff.info\/wordpress\/category\/reading\/"},"img":{"alt_text":"Dead moles on a fence in Yorkshire.","src":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2017\/05\/2464682583_75238b8f03_b_moles-yorkshire.jpg?fit=1024%2C683&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2017\/05\/2464682583_75238b8f03_b_moles-yorkshire.jpg?fit=1024%2C683&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2017\/05\/2464682583_75238b8f03_b_moles-yorkshire.jpg?fit=1024%2C683&ssl=1&resize=525%2C300 1.5x, https:\/\/i0.wp.com\/steelwagstaff.info\/wordpress\/wp-content\/uploads\/2017\/05\/2464682583_75238b8f03_b_moles-yorkshire.jpg?fit=1024%2C683&ssl=1&resize=700%2C400 2x"},"classes":[]}],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/posts\/4777","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/comments?post=4777"}],"version-history":[{"count":1,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/posts\/4777\/revisions"}],"predecessor-version":[{"id":4989,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/posts\/4777\/revisions\/4989"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/media\/5022"}],"wp:attachment":[{"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/media?parent=4777"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/categories?post=4777"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/steelwagstaff.info\/wordpress\/wp-json\/wp\/v2\/tags?post=4777"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}