Care for the dying needs more imagination – and less hospitalisation

‘To die of age is a rare, singular and extra-ordinary death’, wrote Montaigne, ‘and so much less natural than others: it is the last and extremest form of dying.’ Not any more. Thanks to the marvels of modern medicine, we are limping and stumbling and mumbling and forgetting our way into the grave at greater ages than ever before. Since such longevity is still new, we’re not really prepared for it: we are dying beyond our means, outliving our usefulness, our pensions and even our individual body parts. Outliving, too, the patience of our families. In affluent countries like ours, the spectre of the care home holds more menace than death itself.

Atul Gawande is a surgeon, as well as a professor at Harvard Medical School. He writes on medicine and medical ethics for the New Yorker and has published several bestselling books about how to be a better doctor, all of them excellent and of great interest to the lay reader. He has no professional need to worry about old people, nor even to trouble himself unduly about the dying. So it is to his tremendous credit that Gawande has turned his attention to mortality. We need people of such outstanding intelligence and compassion to consider the ever-growing problems associated with our ageing population.

Throughout our lives we visit our doctors as consumers, with the expectation that they will be able to do something: give us pills and potions, zap anything nasty, mend broken bits, replace worn-out joints. This is all well and good until we get to the end. The sad fact is that more NHS money is spent on the last six months of people’s lives than any other stage, with unhappier results. As Gawande says:

“The simple view is that medicine exists to fight death and disease and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don’t want a general who fights to the point of total annihilation.

He argues instead for a shift away from the medicalisation of mortality towards common sense and kindness. Less intervention, more conversation. Fewer hospital procedures and more hospice-type care, where someone is made comfortable and allowed to get on with enjoying life. Gawande admits that doctors — himself included — often can’t face telling their patients of a poor prognosis. Indeed, research shows that the more a doctor likes a patient, the less likely he is to give bad news. Yet, oddly, patients are much happier when they are given the facts and able to discuss their hopes and fears accordingly. Almost everyone says they’d like to die at home: Gawande makes a strong case for this being a better experience for all, families included. He cites research which shows that family members are much less likely to suffer from depression if the deceased died at home rather than in intensive care. It also makes economic sense.

He takes a similar view of old age. We need to find ways in which ‘ordinary people can age without having to choose between neglect and institutionalisation’. He suggests that it is a mistake to think that society worships youth: he believes that what we truly value is independence. But independence tends to get sacrificed to concerns about safety. Gawande doesn’t appear to have heard about abuse in care homes, but he is highly critical of them even so. He believes that such places offer safety at the price of the freedom to make our own choices. The book proposes some attractive solutions, notably various kinds of assisted living. How viable such schemes are to anyone but the well-off is another question.

The elephant in the room is dementia. Those with dementia cannot club together to find a nice handyman who’ll come and change their light bulbs, or arrange a cheery jaunt to the cinema. They can’t do anything, much. They and the people who look after them are stuck in a ghastly limbo and even a mind as fine as Atul Gawande’s cannot find a way out. He is, after all, a doctor: he likes problems that can be solved. In Being Mortal he accepts that he does not have all the answers, but calls for more imagination and invention in the care of the old and the dying. This is a truly important book.