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To Sara Bershtel
Contents
Title Page
Copyright Notice
Dedication
Epigraph
Introduction
1 • The Independent Self
2 • Things Fall Apart
3 • Dependence
4 • Assistance
5 • A Better Life
6 • Letting Go
7 • Hard Conversations
8 • Courage
Epilogue
Notes on Sources
Acknowledgements
Also by Atul Gawande
About the Author
Copyright
I see it now—this world is
swiftly passing.
—the warrior Karna, in the
Mahabharata
They come to rest at any
kerb:
All streets in time are visited.
—Philip Larkin, “Ambulances”
Introduction
I learned about a lot of things
in medical school, but
mortality wasn’t one of them.
Although I was given a dry,
leathery corpse to dissect in
my first term, that was solely
a way to learn about human
anatomy. Our textbooks had
almost nothing on aging or
frailty or dying. How the
process unfolds, how people
experience the end of their
lives, and how it affects those
around them seemed beside
the point. The way we saw it,
and the way our professors
saw it, the purpose of medical
schooling was to teach how to
save lives, not how to tend to
their demise.
The one time I remember
discussing mortality was
during an hour we spent on
The Death of Ivan Ilyich,
Tolstoy’s classic novella. It
was in a weekly seminar
called Patient-Doctor—part
of the school’s effort to make
us more rounded and humane
physicians. Some weeks we
would practice our physical
examination etiquette; other
weeks we’d learn about the
effects of socioeconomics and
race on health. And one
afternoon we contemplated
the suffering of Ivan Ilyich as
he lay ill and worsening from
some unnamed, untreatable
disease.
In the story, Ivan Ilyich is
forty-five years old, a
midlevel Saint Petersburg
magistrate
whose
life
revolves mostly around petty
concerns of social status. One
day, he falls off a stepladder
and develops a pain in his
side. Instead of abating, the
pain gets worse, and he
becomes unable to work.
Formerly an “intelligent,
polished, lively and agreeable
man,” he grows depressed
and enfeebled. Friends and
colleagues avoid him. His
wife calls in a series of ever
more expensive doctors.
None of them can agree on a
diagnosis, and the remedies
they give him accomplish
nothing. For Ilyich, it is all
torture, and he simmers and
rages at his situation.
“What tormented Ivan
Ilyich most,” Tolstoy writes,
“was the deception, the lie,
which for some reason they
all accepted, that he was not
dying but was simply ill, and
he only need keep quiet and
undergo a treatment and then
something very good would
result.” Ivan Ilyich has
flashes of hope that maybe
things will turn around, but as
he grows weaker and more
emaciated he knows what is
happening. He lives in
mounting anguish and fear of
death. But death is not a
subject that his doctors,
friends, or family can
countenance. That is what
causes him his most profound
pain.
“No one pitied him as he
wished to be pitied,” writes
Tolstoy. “At certain moments
after prolonged suffering he
wished most of all (though he
would have been ashamed to
confess it) for someone to
pity him as a sick child is
pitied. He longed to be petted
and comforted. He knew he
was an important functionary,
that he had a beard turning
grey, and that therefore what
he longed for was impossible,
but still he longed for it.”
As we medical students
saw it, the failure of those
around Ivan Ilyich to offer
comfort or to acknowledge
what is happening to him was
a failure of character and
culture. The late-nineteenthcentury Russia of Tolstoy’s
story seemed harsh and
almost primitive to us. Just as
we believed that modern
medicine could probably have
cured Ivan Ilyich of whatever
disease he had, so too we
took for granted that honesty
and kindness were basic
responsibilities of a modern
doctor. We were confident
that in such a situation we
would act compassionately.
What worried us was
knowledge. While we knew
how to sympathize, we
weren’t at all certain we
would know how to properly
diagnose and treat. We paid
our medical tuition to learn
about the inner process of the
body,
the
intricate
mechanisms
of
its
pathologies, and the vast
trove of discoveries and
technologies
that
have
accumulated to stop them.
We didn’t imagine we needed
to think about much else. So
we put Ivan Ilyich out of our
heads.
Yet within a few years,
when I came to experience
surgical training and practice,
I encountered patients forced
to confront the realities of
decline and mortality, and it
did not take long to realize
how unready I was to help
them.
* * *
I BEGAN WRITING when I was a
junior surgical resident, and
in one of my very first essays,
I told the story of a man
whom I called Joseph
Lazaroff. He was a city
administrator who’d lost his
wife to lung cancer a few
years earlier. Now, he was in
his sixties and suffering from
an incurable cancer himself—
a widely metastatic prostate
cancer. He had lost more than
fifty pounds. His abdomen,
scrotum, and legs had filled
with fluid. One day, he woke
up unable to move his right
leg or control his bowels. He
was admitted to the hospital,
where I met him as an intern
on the neurosurgical team.
We found that the cancer had
spread to his thoracic spine,
where it was compressing his
spinal cord. The cancer
couldn’t be cured, but we
hoped it could be treated.
Emergency
radiation,
however, failed to shrink the
cancer,
and
so
the
neurosurgeon offered him
two options: comfort care or
surgery to remove the
growing tumor mass from his
spine. Lazaroff chose surgery.
My job, as the intern on the
neurosurgery service, was to
get his written confirmation
that he understood the risks of
the operation and wished to
proceed.
I’d stood outside his room,
his chart in my damp hand,
trying to figure out how to
even broach the subject with
him. The hope was that the
operation would halt the
progression of his spinal cord
damage. It wouldn’t cure
him, or reverse his paralysis,
or get him back to the life he
had led. No matter what we
did he had at most a few
months to live, and the
procedure was inherently
dangerous.
It
required
opening his chest, removing a
rib, and collapsing a lung to
get at his spine. Blood loss
would be high. Recovery
would be difficult. In his
weakened state, he faced
considerable
risks
of
debilitating
complications
afterward. The operation
posed a threat of both
worsening and shortening his
life. But the neurosurgeon
had gone over these dangers,
and Lazaroff had been clear
that he wanted the operation.
All I had to do was go in and
take care of the paperwork.
Lying in his bed, Lazaroff
looked gray and emaciated. I
said that I was an intern and
that I’d come to get his
consent for surgery, which
required confirming that he
was aware of the risks. I said
that the operation could
remove the tumor but leave
him
with
serious
complications,
such
as
paralysis or a stroke, and that
it could even prove fatal. I
tried to sound clear without
being
harsh,
but
my
discussion put his back up.
Likewise when his son, who
was in the room, questioned
whether heroic measures
were a good idea. Lazaroff
didn’t like that at all.
“Don’t you give up on
me,” he said. “You give me
every chance I’ve got.”
Outside the room, after he
signed the form, the son took
me aside. His mother had
died on a ventilator in
intensive care, and at the time
his father had said he did not
want anything like that to
happen to him. But now he
was adamant about doing
“everything.”
I believed then that Mr.
Lazaroff had chosen badly,
and I still believe this. He
chose badly not because of all
the dangers but because the
operation didn’t stand a
chance of giving him what he
really wanted: his continence,
his strength, the life he had
previously known. He was
pursuing little more than a
fantasy at the risk of a
prolonged and terrible death
—which was precisely what
he got.
The operation was a
technical success. Over eight
and a half hours, the surgical
team removed the mass
invading his spine and rebuilt
the vertebral body with
acrylic cement. The pressure
on his spinal cord was gone.
But he never recovered from
the procedure. In intensive
care, he developed respiratory
failure, a systemic infection,
blood
clots
from
his
immobility, then bleeding
from the blood thinners to
treat them. Each day we fell
further behind. We finally
had to admit he was dying.
On the fourteenth day, his son
told the team that we should
stop.
It fell to me to take
Lazaroff off the artificial
ventilator that was keeping
him alive. I checked to make
sure that his morphine drip
was turned up high, so he
wouldn’t suffer from air
hunger. I leaned close and, in
case he could hear me, said I
was going to take the
breathing tube out of his
mouth. He coughed a couple
of times when I pulled it out,
opened his eyes briefly, and
closed them. His breathing
grew labored, then stopped. I
put my stethoscope on his
chest and heard his heart fade
away.
Now, more than a decade
after I first told Mr.
Lazaroff’s story, what strikes
me most is not how bad his
decision was but how much
we all avoided talking
honestly about the choice
before him. 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.
We did little better than
Ivan
Ilyich’s
primitive
nineteenth-century doctors—
worse, actually, given the
new forms of physical torture
we’d inflicted on our patient.
It is enough to make you
wonder, who are the primitive
ones.
* * *
MODERN
CAPABILITY
SCIENTIFIC
has profoundly
altered the course of human
life. People live longer and
better than at any other time
in history. But scientific
advances have turned the
processes of aging and dying
into medical experiences,
matters to be managed by
health care professionals.
And we in the medical world
have
proved
alarmingly
unprepared for it.
This reality has been
largely hidden, as the final
phases of life become less
familiar to people. As
recently as 1945, most deaths
occurred in the home. By the
1980s, just 17 percent did.
Those who somehow did die
at home likely died too
suddenly to make it to the
hospital—say,
from
a
massive heart attack, stroke,
or violent injury—or were too
isolated to get somewhere
that could provide help.
Across not just the United
States but also the entire
industrialized world, the
experience of advanced aging
and death has shifted to
hospitals and nursing homes.
When I became a doctor, I
crossed over to the other side
of the hospital doors and,
although I had grown up with
two doctors for parents,
everything I saw was new to
me. I had certainly never seen
anyone die before and when I
did it came as a shock. That
wasn’t because it made me
think of my own mortality.
Somehow the concept didn’t
occur to me, even when I saw
people my own age die. I had
a white coat on; they had a
hospital gown. I couldn’t
quite picture it the other way
round. I could, however,
picture my family in their
places. I’d seen multiple
family members—my wife,
my parents, and my children
—go through serious, lifethreatening illnesses. Even
under dire circumstances,
medicine had always pulled
them through. The shock to
me therefore was seeing
medicine not pull people
through. I knew theoretically
that my patients could die, of
course, but every actual
instance seemed like a
violation, as if the rules I
thought we were playing by
were broken. I don’t know
what game I thought this was,
but in it we always won.
Dying and death confront
every new doctor and nurse.
The first times, some cry.
Some shut down. Some
hardly notice. When I saw my
first deaths, I was too guarded
to cry. But I dreamt about
them. I had recurring
nightmares in which I’d find
my patients’ corpses in my
house—in my own bed.
“How did he get here?” I’d
wonder in panic.
I knew I would be in huge
trouble, maybe criminal
trouble, if I didn’t get the
body back to the hospital
without getting caught. I’d try
to lift it into the back of my
car, but it would be too
heavy. Or I’d get it in, only to
find blood seeping out like
black oil until it overflowed
the trunk. Or I’d actually get
the corpse to the hospital and
onto a gurney, and I’d push it
down hall after hall, trying
and failing to find the room
where the person used to be.
“Hey!” someone would shout
and start chasing me. I’d
wake up next to my wife in
the dark, clammy and
tachycardic. I felt that I’d
killed these people. I’d failed.
Death, of course, is not a
failure. Death is normal.
Death may be the enemy, but
it is also the natural order of
things. I knew these truths
abstractly, but I didn’t know
them concretely—that they
could be truths not just for
everyone but also for this
person right in front of me,
for this person I was
responsible for.
The late surgeon Sherwin
Nuland, in his classic book
How We Die, lamented, “The
necessity of nature’s final
victory was expected and
accepted
in
generations
before our own. Doctors were
far more willing to recognize
the signs of defeat and far
less arrogant about denying
them.” But as I ride down the
runway of the twenty-first
century, trained in the
deployment of our awesome
arsenal of technology, I
wonder exactly what being
less arrogant really means.
You become a doctor for
what you imagine to be the
satisfaction of the work, and
that turns out to be the
satisfaction of competence. It
is a deep satisfaction very
much like the one that a
carpenter experiences in
restoring a fragile antique
chest or that a science teacher
experiences in bringing a fifth
grader to that sudden, mindshifting recognition of what
atoms are. It comes partly
from being helpful to others.
But it also comes from being
technically skilled and able to
solve
difficult,
intricate
problems. Your competence
gives you a secure sense of
identity. For a clinician,
therefore, nothing is more
threatening to who you think
you are than a patient with a
problem you cannot solve.
There’s no escaping the
tragedy of life, which is that
we are all aging from the day
we are born. One may even
come to understand and
accept this fact. My dead and
dying patients don’t haunt my
dreams anymore. But that’s
not the same as saying one
knows how to cope with what
cannot be mended. I am in a
profession that has succeeded
because of its ability to fix. If
your problem is fixable, we
know just what to do. But if
it’s not? The fact that we
have had no adequate
answers to this question is
troubling and has caused
callousness, inhumanity, and
extraordinary suffering.
This experiment of making
mortality
a
medical
experience is just decades
old. It is young. And the
evidence is it is failing.
* * *
book about the
modern
experience
of
mortality—about what it’s
THIS IS A
like to be creatures who age
and die, how medicine has
changed the experience and
how it hasn’t, where our ideas
about how to deal with our
finitude have got the reality
wrong. As I pass a decade in
surgical practice and become
middle-aged myself, I find
that neither I nor my patients
find our current state
tolerable. But I have also
found it unclear what the
answers should be, or even
whether any adequate ones
are possible. I have the
writer’s and scientist’s faith,
however, that by pulling back
the veil and peering in close,
a person can make sense of
what is most confusing or
strange or disturbing.
You don’t have to spend
much time with the elderly or
those with terminal illness to
see how often medicine fails
the people it is supposed to
help. The waning days of our
lives are given over to
treatments that addle our
brains and sap our bodies for
a sliver’s chance of benefit.
They are spent in institutions
—nursing
homes
and
intensive care units—where
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.
I wrote this book in the
hope of understanding what
has happened. Mortality can
be a treacherous subject.
Some will be alarmed by the
prospect of a doctor’s writing
about the inevitability of
decline and death. For many,
such talk, however carefully
framed, raises the specter of a
society readying itself to
sacrifice its sick and aged.
But what if the sick and aged
are already being sacrificed
—victims of our refusal to
accept the inexorability of our
life cycle? And what if there
are better approaches, right in
front of our eyes, waiting to
be recognized?
1 • The Independent
Self
Growing
up,
I
never
witnessed serious illness or
the difficulties of old age. My
parents, both doctors, were fit
and healthy. They were
immigrants
from
India,
raising me and my sister in
the small college town of
Athens,
Ohio,
so
my
grandparents were far away.
The one elderly person I
regularly encountered was a
woman down the street who
gave me piano lessons when I
was in middle school. Later
she got sick and had to move
away, but it didn’t occur to
me to wonder where she went
and what happened to her.
The experience of a modern
old age was entirely outside
my perception.
In college, however, I
began dating a girl in my
dorm named Kathleen, and in
1985, on a Christmas visit to
her home in Alexandria,
Virginia,
I
met
her
grandmother Alice Hobson,
who was seventy-seven at the
time. She struck me as
spirited and independent
minded. She never tried to
disguise her age. Her undyed
white hair was brushed
straight and parted on one
side, Bette Davis–style. Her
hands were speckled with age
spots, and her skin was
crinkled. She wore simple,
neatly pressed blouses and
dresses, a bit of lipstick, and
heels long past when others
would have considered it
advisable.
As I came to learn over the
years—for I would eventually
marry Kathleen—Alice grew
up in a rural Pennsylvania
town known for its flower
and mushroom farms. Her
father was a flower farmer,
growing
carnations,
marigolds, and dahlias, in
acres of greenhouses. Alice
and her siblings were the first
members of their family to
attend college. At the
University of Delaware, Alice
met Richmond Hobson, a
civil engineering student.
Thanks
to
the
Great
Depression, it wasn’t until six
years after their graduation
that they could afford to get
married. In the early years,
Alice and Rich moved often
for his work. They had two
children, Jim, my future
father-in-law,
and
then
Chuck. Rich was hired by the
Army Corps of Engineers and
became an expert in large
dam and bridge construction.
A decade later, he was
promoted to a job working
with the corps’s chief
engineer at headquarters
outside Washington, DC,
where he remained for the
rest of his career. He and
Alice settled in Arlington.
They bought a car, took road
trips far and wide, and put
away some money, too. They
were able to upgrade to a
bigger house and send their
brainy kids off to college
without need of loans.
Then, on a business trip to
Seattle, Rich had a sudden
heart attack. He’d had a
history of angina and took
nitroglycerin tablets to relieve
the occasional bouts of chest
pain, but this was 1965, and
back then doctors didn’t have
much they could do about
heart disease. He died in the
hospital before Alice could
get there. He was just sixty
years old. Alice was fifty-six.
With her pension from the
Army Corps of Engineers,
she was able to keep her
Arlington home. When I met
her, she’d been living on her
own in that house on
Greencastle Street for twenty
years. My in-laws, Jim and
Nan, were nearby, but Alice
lived
completely
independently. She mowed
her own lawn and knew how
to fix the plumbing. She went
to the gym with her friend
Polly. She liked to sew and
knit and made clothes,
scarves, and elaborate redand-green
Christmas
stockings for everyone in the
family, complete with a
button-nosed Santa and their
names across the top. She
organized a group that took
an annual subscription to
attend performances at the
Kennedy Center for the
Performing Arts. She drove a
big V8 Chevrolet Impala,
sitting on a cushion to see
over the dashboard. She ran
errands, visited family, gave
friends rides, and delivered
meals-on-wheels for those
with more frailties than
herself.
As time went on, it became
hard not to wonder how much
longer she’d be able to
manage. She was a petite
woman, five feet tall at most,
and although she bristled
when anyone suggested it,
she lost some height and
strength with each passing
year. When I married her
granddaughter, Alice beamed
and held me close and told
me how happy the wedding
made her, but she’d become
too arthritic to share a dance
with me. And still she
remained in her home,
managing on her own.
When my father met her,
he was surprised to learn she
lived by herself. He was a
urologist, which meant he
saw many elderly patients,
and it always bothered him to
find them living alone. The
way he saw it, if they didn’t
already have serious needs,
they were bound to develop
them, and coming from India
he felt it was the family’s
responsibility to take the aged
in, give them company, and
look after them. Since
arriving in New York City in
1963 for his residency
training, my father had
embraced virtually every
aspect of American culture.
He gave up vegetarianism
and discovered dating. He got
a girlfriend, a pediatrics
resident from a part of India
where they didn’t speak his
language. When he married
her, instead of letting my
grandfather
arrange
his
marriage, the family was
scandalized. He became a
tennis enthusiast, president of
the local Rotary Club, and
teller of bawdy jokes. One of
his proudest days was July 4,
1976,
the
country’s
bicentennial, when he was
made an American citizen in
front of hundreds of cheering
people in the grandstand at
the Athens County Fair
between the hog auction and
the demolition derby. But one
thing he could never get used
to was how we treat our old
and frail—leaving them to a
life alone or isolating them in
a series of anonymous
facilities, their last conscious
moments spent with nurses
and doctors who barely knew
their names. Nothing could
have been more different
from the world he had grown
up in.
* * *
MY FATHER’S FATHER had the
kind of traditional old age
that,
from
a
Western
perspective, seems idyllic.
Sitaram Gawande was a
farmer in a village called Uti,
some three hundred miles
inland from Mumbai, where
our ancestors had cultivated
land
for
centuries.
I
remember visiting him with
my parents and sister around
the same time I met Alice,
when he was more than a
hundred years old. He was,
by far, the oldest person I’d
ever known. He walked with
a cane, stooped like a bent
stalk of wheat. He was so
hard of hearing that people
had to shout in his ear
through a rubber tube. He
was weak and sometimes
needed help getting up from
sitting. But he was a dignified
man, with a tightly wrapped
white turban, a pressed,
brown argyle cardigan, and a
pair of old-fashioned, thicklensed, Malcolm X–style
spectacles.
He
was
surrounded and supported by
family at all times, and he
was revered—not in spite of
his age but because of it. He
was
consulted
on
all
important
matters—
marriages, land disputes,
business
decisions—and
occupied a place of high
honor in the family. When we
ate, we served him first.
When young people came
into his home, they bowed
and touched his feet in
supplication.
In America, he would
almost certainly have been
placed in a nursing home.
Health professionals have a
formal classification system
for the level of function a
person has. If you cannot,
without assistance, use the
toilet, eat, dress, bathe,
groom, get out of bed, get out
of a chair, and walk—the
eight “Activities of Daily
Living”—then you lack the
capacity for basic physical
independence. If you cannot
shop for yourself, prepare
your own food, maintain your
housekeeping,
do
your
laundry,
manage
your
medications, make phone
calls, travel on your own, and
handle your finances—the
eight “Independent Activities
of Daily Living”—then you
lack the capacity to live
safely on your own.
My grandfather could
perform only some of the
basic
measures
of
independence, and few of the
more complex ones. But in
India, this was not of any dire
consequence. His situation
prompted no family crisis
meeting,
no
anguished
debates over what to do with
him. It was clear that the
family would ensure my
grandfather could continue to
live as he desired. One of my
uncles and his family lived
with him, and with a small
herd
of
children,
grandchildren, nieces, and
nephews nearby, he never
lacked for help.
The arrangement allowed
him to maintain a way of life
that few elderly people in
modern societies can count
on. The family made it
possible, for instance, for him
to continue to own and
manage his farm, which he
had built up from nothing—
indeed, from worse than
nothing. His father had lost
all but two mortgaged acres
and two emaciated bulls to a
moneylender
when
the
harvest failed one year. He
then died, leaving Sitaram,
his eldest son, with the debts.
Just eighteen years old and
newly married, Sitaram was
forced
to
enter
into
indentured labor on the
family’s two remaining acres.
At one point, the only food he
and his bride could afford
was bread and salt. They
were starving to death. But he
prayed and stayed at the
plow, and his prayers were
answered. The harvest was
spectacular. He was able to
not only put food on the table
but also pay off his debts. In
subsequent
years,
he
expanded his two acres to
more than two hundred. He
became one of the richest
landowners in the village and
a moneylender himself. He
had three wives, all of whom
he outlived, and thirteen
children. He emphasized
education,
hard
work,
frugality, earning your own
way, staying true to your
word, and holding others
strictly accountable for doing
the same. Throughout his life,
he awoke before sunrise and
did not go to bed until he’d
done a nighttime inspection
of every acre of his fields by
horse. Even when he was a
hundred he would insist on
doing this. My uncles were
worried he’d fall—he was
weak and unsteady—but they
knew it was important to him.
So they got him a smaller
horse and made sure that
someone
always
accompanied him. He made
the rounds of his fields right
up to the year he died.
Had he lived in the West,
this would have seemed
absurd. It isn’t safe, his
doctor would say. If he
persisted, then fell, and went
to an emergency room with a
broken hip, the hospital
would not let him return
home. They’d insist that he
go to a nursing home. But in
my grandfather’s premodern
world, how he wanted to live
was his choice, and the
family’s role was to make it
possible.
My grandfather finally died
at the age of almost a hundred
and ten. It happened after he
hit his head falling off a bus.
He was going to the
courthouse in a nearby town
on business, which itself
seems crazy, but it was a
priority to him. The bus
began to move while he was
getting off and, although he
was accompanied by family,
he fell. Most probably, he
developed
a
subdural
hematoma—bleeding inside
his skull. My uncle got him
home, and over the next
couple of days he faded
away. He got to live the way
he wished and with his family
around him right to the end.
* * *
FOR MOST OF human history,
for those few people who
actually survived to old age,
Sitaram
Gawande’s
experience was the norm.
Elders were cared for in
multigenerational
systems,
often with three generations
living under one roof. Even
when the nuclear family
replaced the extended family
(as it did in northern Europe
several centuries ago), the
elderly were not left to cope
with the infirmities of age on
their own. Children typically
left home as soon as they
were old enough to start
families of their own. But one
child usually remained, often
the youngest daughter, if the
parents
survived
into
senescence. This was the lot
of the poet Emily Dickinson,
in Amherst, Massachusetts, in
the mid-nineteenth century.
Her elder brother left home,
married, and started a family,
but she and her younger sister
stayed with their parents until
they died. As it happened,
Emily’s father lived to the
age of seventy-one, by which
time she was in her forties,
and her mother lived even
longer. She and her sister
ended up spending their
entire lives in the parental
home.
As different as Emily
Dickinson’s parents’ life in
America seems from that of
Sitaram Gawande’s in India,
both relied on systems that
shared the advantage of easily
resolving the question of care
for the elderly. There was no
need to save up for a spot in a
nursing home or arrange for
meals-on-wheels. It was
understood that parents would
just keep living in their home,
assisted by one or more of the
children they’d raised. In
contemporary societies, by
contrast, old age and infirmity
have gone from being a
shared,
multigenerational
responsibility to a more or
less private state—something
experienced largely alone or
with the aid of doctors and
institutions. How did this
happen? How did we go from
Sitaram Gawande’s life to
Alice Hobson’s?
One answer is that old age
itself has changed. In the past,
surviving into old age was
uncommon, and those who
did survive served a special
purpose as guardians of
tradition, knowledge, and
history. They tended to
maintain their status and
authority as heads of the
household until death. In
many societies, elders not
only commanded respect and
obedience but also led sacred
rites and wielded political
power. So much respect
accrued to the elderly that
people used to pretend to be
older than they were, not
younger, when giving their
age. People have always lied
about how old they are.
Demographers
call
the
phenomenon “age heaping”
and have devised complex
quantitative contortions to
correct for all the lying in
censuses. They 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.
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.
As for the exclusive hold
that elders once had on
knowledge and wisdom, that,
too, has eroded, thanks to
technologies
of
communication—starting
with writing itself and
extending to the Internet and
beyond. New technology also
creates new occupations and
requires new expertise, which
further undermines the value
of long experience and
seasoned judgment. At one
time, we might have turned to
an old-timer to explain the
world. Now we consult
Google, and if we have any
trouble with the computer we
ask a teenager.
Perhaps most important of
all, increased longevity has
brought about a shift in the
relationship between the
young
and
the
old.
Traditionally,
surviving
parents provided a source of
much-needed
stability,
advice,
and
economic
protection for young families
seeking pathways to security.
And because landowners also
tended to hold on to their
property until death, the child
who sacrificed everything to
care for the parents could
expect to inherit the whole
homestead, or at least a larger
portion than a child who
moved away. But once
parents were living markedly
longer lives, tension emerged.
For young people, the
traditional family system
became less a source of
security than a struggle for
control—over
property,
finances, and even the most
