Being Mortal: Medicine and What Matters in the End

by Gawande, Atul

  These were stunning results. If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices.

  Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.

  How do we reward this kind of work? Chad Boult, the geriatrician who was the lead investigator of the University of Minnesota study, can tell you. A few months after he published the results, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

  “The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he had moved to join the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a $25,000 pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good. Meanwhile, the twenty-plus members of the proven geriatrics team at the University of Minnesota had to find new jobs. Scores of medical centers across the country have shrunk or closed their geriatrics units. Many of Boult’s colleagues no longer advertise their geriatric training for fear that they’ll get too many elderly patients. “Economically, it has become too difficult,” Boult said.

  But the dismal finances of geriatrics are only a symptom of a deeper reality: people have not insisted on a change in priorities. We all like new medical gizmos and demand that policy makers ensure they are paid for. We want doctors who promise to fix things. But geriatricians? Who clamors for geriatricians? What geriatricians do—bolster our resilience in old age, our capacity to weather what comes—is both difficult and unappealingly limited. It requires attention to the body and its alterations. It requires vigilance over nutrition, medications, 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’s uncomfortable demand is that we accept we are not.

  * * *

  FOR FELIX SILVERSTONE, managing aging and its distressing realities was the work of a lifetime. He was a national leader in geriatrics for five decades. But when I met him he was himself eighty-seven years old. He could feel his own mind and body wearing down, and much of what he spent his career studying was no longer at a remove from him.

  Felix had been fortunate. He didn’t have to stop working, even after he suffered a heart attack in his sixties that cost him half his heart function; nor was he stopped by a near cardiac arrest at the age of seventy-nine.

  “One evening, sitting at home, I suddenly became aware of palpitations,” he told me. “I was just reading, and a few minutes later I became short of breath. A little bit after that, I began to feel heavy in the chest. I took my pulse, and it was over two hundred.”

  He is the sort of person who, in the midst of chest pain, would take the opportunity to examine his own pulse.

  “My wife and I had a little discussion about whether or not to call an ambulance. We decided to call.”

  When Felix got to the hospital, the doctors had to shock him to bring his heart back. He’d had ventricular tachycardia, and an automatic defibrillator was implanted in his chest. Within a few weeks, he felt well again, and his doctor cleared him to return to work full time. He stayed in medical practice after the attack, multiple hernia repairs, gallbladder surgery, arthritis that all but ended his avid piano playing, compression fractures of his aging spine that stole three full inches of his five-foot-seven-inch height, and hearing loss.

  “I switched to an electronic stethoscope,” he said. “They’re a nuisance, but they’re very good.”

  Finally, at eighty-two, he had to retire. The problem wasn’t his health; it was that of his wife, Bella. They’d been married for more than sixty years. Felix had met Bella when he was an intern and she was a dietitian at Kings County Hospital, in Brooklyn. They brought up two sons in Flatbush. When the boys left home, Bella got her teaching certificate and began working with children who had learning disabilities. In her seventies, however, retinal disease diminished her vision, and she had to stop working. A decade later, she’d become almost completely blind. Felix no longer felt safe leaving her at home alone, and in 2001 he gave up his practice. They moved to Orchard Cove, a retirement community in Canton, Massachusetts, outside Boston, where they could be closer to their sons.

  “I didn’t think I would survive the change,” Felix said. He’d observed in his patients how difficult the transitions of age were. Examining his last patient, packing up his home, he felt that he was about to die. “I was taking apart my life as well as the house,” he recalled. “It was terrible.”

  We were sitting in a library off Orchard Cove’s main lobby. There was light streaming through a picture window, tasteful art on the walls, white upholstered Federal-style armchairs. It was like a nice hotel, only with no one under seventy-five walking around. Felix and Bella had a two-bedroom apartment with forest views and plenty of space. In the living room, Felix had a grand piano and, at his desk, piles of medical journals that he still subscribed to—“for my soul,” he said. Theirs was an independent-living unit. It came with housekeeping, linen changes, and dinner each evening. When they needed to, they could upgrade to assisted living, which provides three prepared meals and up to an hour with a personal-care assistant each day.

  This was not the average retirement community, but even in an average one rent runs $32,000 a year. Entry fees are typically $60,000 to $120,000 on top of that. Meanwhile, the median income of people eighty and older is only about $15,000. More than half of the elderly living in long-term-care facilities run through their entire savings and have to go on government assistance—welfare—in order to afford it. Ultimately, the average American spends a year or more of old age disabled and living in a nursing home (at more than five times the yearly cost of independent living), which is a destination Felix was desperately hoping to avoid.

  He was trying to note the changes he experienced objectively, like the geriatrician he is. He noticed that his skin had dried out. His sense of smell was diminished. His night vision had become poor, and he tired easily. He had begun to lose teeth. But he took what measures he could. He used lotion to avoid skin cracks; he protected himself from the heat; he got on an exercise bike three times a week; he saw a dentist twice a year.

  He was most concerned about the changes in his brain. “I can’t think as clearly as I used to,” he said. “I used to be able to read the New York Times in half an hour. Now it takes me an hour and a half.” Even then, he wasn’t sure that he understood as much as he did before, and his memory gave him trouble. “If I go back and look at what I’ve read, I recognize that I went through it, but sometimes I don’t really remember it,” he said. “It’s a matter of short-term registration. It’s hard to get the signal in and have it stay put.”

  He made use of methods that he once taught his patients. “I try to deliberately focus on what I’m doing, rather than do it automatically,” he told me. “I haven’t lost the aut
omaticity of action, but I can’t rely on it the way I used to. For example, I can’t think about something else and get dressed and be sure I’ve gotten all the way dressed.” He recognized that the strategy of trying to be more deliberate didn’t always work, and he sometimes told me the same story twice in a conversation. The lines of thought in his mind would fall into well-worn grooves and, however hard he tried to put them onto a new path, sometimes they resisted. Felix’s knowledge as a geriatrician forced him to recognize his decline, but it didn’t make it easier to accept.

  “I get blue occasionally,” he said. “I think I have recurring episodes of depression. They are not enough to disable me, but they are…” He paused to find the right word. “They are uncomfortable.”

  What buoyed him, despite his limitations, was having a purpose. It was the same purpose, he said, that sustained him in medicine: to be of service, in some way, to those around him. He had been in Orchard Cove for only a few months before he was helping to steer a committee to improve the health care services there. He formed a journal-reading club for retired physicians. He even guided a young geriatrician through her first independent research study—a survey of the residents’ attitudes toward Do Not Resuscitate orders.

  More important was the responsibility that he felt for his children and grandchildren—and most of all for Bella. Her blindness and memory troubles had made her deeply dependent. Without him, she would have been in a nursing home. He helped her dress and administered her medicines. He made her breakfast and lunch. He took her on walks and to doctor’s appointments. “She is my purpose now,” he said.

  Bella didn’t always like his way of doing things.

  “We argue constantly—we’re at each other about a lot of things,” Felix said. “But we’re also very forgiving.”

  He did not feel this responsibility to be a burden. With the narrowing of his own life, his ability to look after Bella had become his main source of self-worth.

  “I am exclusively her caregiver,” he said. “I am glad to be.” And this role had heightened his sense that he must be attentive to the changes in his own capabilities; he would be no good to her if he wasn’t honest with himself about his own limitations.

  One evening, Felix invited me to dinner. The formal dining hall was restaurant-like, with reserved seating, table service, and jackets required. I was wearing my white hospital coat and had to borrow a navy blazer from the maître d’ in order to be seated. Felix, in a brown suit and a stone-colored oxford shirt, gave his arm to Bella, who wore a blue-flowered knee-length dress that he’d picked out for her, and guided her to the table. She was amiable and chatty and had youthful-seeming eyes. But once she’d been seated, she couldn’t find the plate in front of her, let alone the menu. Felix ordered for her: wild-rice soup, an omelette, mashed potatoes, and mashed cauliflower. “No salt,” he instructed the waiter; she had high blood pressure. He ordered salmon and mashed potatoes for himself. I had the soup and a London broil.

  When the food arrived, Felix told Bella where she could find the different items on her plate by the hands of a clock. He put a fork in her hand. Then he turned to his own meal.

  Both made a point of chewing slowly. She was the first to choke. It was the omelette. Her eyes watered. She began to cough. Felix guided her water glass to her mouth. She took a drink and managed to get the omelette down.

  “As you get older, the lordosis of your spine tips your head forward,” he said to me. “So when you look straight ahead it’s like looking up at the ceiling for anyone else. Try to swallow while looking up: you’ll choke once in a while. The problem is common in the elderly. Listen.” I realized that I could hear someone in the dining room choking on his food every minute or so. Felix turned to Bella. “You have to eat looking down, sweetie,” he said.

  A couple of bites later, though, he himself was choking. It was the salmon. He began coughing. He turned red. Finally, he was able to cough up the bite. It took a minute for him to catch his breath.

  “Didn’t follow my own advice,” he said.

  Felix Silverstone was, without question, up against the debilities of his years. Once, it would have been remarkable simply to have lived to see eighty-seven. Now the remarkable thing was the control he’d maintained over his life. When he started in geriatric practice, it was almost inconceivable that an eighty-seven-year-old with his history of health problems could live independently, care for his disabled wife, and continue to contribute to research.

  Partly, he had been lucky. His memory, for example, had not deteriorated badly. But he had also managed his old age well. His goal has been modest: to have as decent a life as medical knowledge and the limits of his body would allow. So he saved and did not retire early and was therefore not in financial straits. He kept his social contacts and avoided isolation. He monitored his bones and teeth and weight. And he made sure to find a doctor who had the geriatric skills to help him hold on to an independent life.

  * * *

  I ASKED CHAD Boult, the geriatrics professor, what could be done to ensure that there are enough geriatricians for the surging elderly population. “Nothing,” he said. “It’s too late.” Creating geriatric specialists takes time, and we already have far too few. In a year, fewer than three hundred doctors will complete geriatrics training in the United States, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade. Geriatric psychiatrists, nurses, and social workers are equally needed, and in no better supply. The situation in countries outside the United States appears to be little different. In many, it is worse.

  Yet Boult believes that we still have time for another strategy: he would direct geriatricians toward training all primary care doctors and nurses in caring for the very old, instead of providing the care themselves. Even this is a tall order—97 percent of medical students take no course in geriatrics, and the strategy requires that the nation pay geriatric specialists to teach rather than to provide patient care. But if the will is there, Boult estimates that it would be possible to establish courses in every medical school, nursing school, school of social work, and internal-medicine training program within a decade.

  “We’ve got to do something,” he said. “Life for older people can be better than it is today.”

  * * *

  “I CAN STILL drive, you know,” Felix Silverstone said to me after our dinner together. “I’m a very good driver.”

  He had to run an errand to refill Bella’s prescriptions in Stoughton, a few miles away, and I asked if I could come along. He had a ten-year-old gold Toyota Camry with automatic transmission and 39,000 miles on the odometer. It was pristine, inside and out. He backed out of a narrow parking space and zipped out of the garage. His hands did not shake. Taking the streets of Canton at dusk on a new-moon night, he brought the car to an even stop at the red lights, signaled when he was supposed to, took turns without a hitch.

  I was, I admit, braced for disaster. The risk of a fatal car crash with a driver who’s 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. I thought of Alice’s wreck and considered how lucky she was that no child had been in her neighbor’s yard. A few months earlier, in Los Angeles, George Weller was convicted of manslaughter after he confused the accelerator with the brake pedal and plowed his Buick into a crowd of shoppers at the Santa Monica Farmers Market. Ten people were killed, and more than sixty were injured. He was eighty-six.

  But Felix showed no difficulties. At one point during our drive, poorly marked road construction at an intersection channeled our line of cars almost directly into oncoming traffic. Felix corrected course swiftly, pulling over into the proper lane. There was no saying how much longer he would be able to count on his driving ability. Someday, the hour would come when he would have to give up his keys.

  At that moment, though, he wasn’t concerned; he was glad simply to be on the road. The evening traffic was thi
n as he turned onto Route 138. He brought the Camry to a tick over the 45-mile-per-hour speed limit. He had his window rolled down and his elbow on the sash. The air was clear and cool, and we listened to the sound of the wheels on the pavement.

  “The night is lovely, isn’t it?” he said.

  3 • Dependence

  It is not death that the very old tell me they fear. It is what happens short of death—losing their hearing, their memory, their best friends, their way of life. As Felix put it to me, “Old age is a continuous series of losses.” Philip Roth put it more bitterly in his novel Everyman: “Old age is not a battle. Old age is a massacre.”

  With luck and fastidiousness—eating well, exercising, keeping our blood pressure under control, getting medical help when we need it—people can often live and manage a very long time. But eventually the losses accumulate to the point where life’s daily requirements become more than we can physically or mentally manage on our own. 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 eventuality. As a result, most of us are unprepared for it. We rarely pay more than glancing attention to how we will live when we need help until it’s too late to do much about it.

  When Felix came to this crossroads, the orthopedic shoe to drop wasn’t his. It was Bella’s. Year by year, I witnessed the progression in her difficulties. Felix remained in astonishingly good health right into his nineties. He had no medical crises and maintained his weekly exercise regimen. He continued to teach chaplaincy students about geriatrics and to serve on Orchard Cove’s health committee. He didn’t even have to stop driving. But Bella was fading. She lost her vision completely. Her hearing became poor. Her memory became markedly impaired. When we had dinner, she had to be reminded more than once that I was sitting across from her.