Thoughts On Atul Gawande's 'Being Mortal: Medicine and What Matters in the End'

One of the reasons that I've enjoyed this book is due to the frequency with which Gawande used his knowledge of medicine to associate his ideas with common sociological interactions. In a striking example of this, Gawande referenced an idea of Erving Goffman. Goffman wrote, 'A basic social arrangement in modern society is that the individual tends to sleep, play, and work in different places, with different co-participants, under different authorities, and without an over-all rational plan.'. This was true when I paused to reflect upon Goffman's statement. People have social settings in which our roles, behaviors, and interactions differ. Seperate activities that I engage in throughout my day are carried out in completely different locations. Even for college students that live out their lives on campus, the activities of their day are carried out in different settings. I'm going to directly quote Gawande's response to Goffman's statement becasue Gawande cleary and precisely laid out a portion nursing home culture in a way that brough tme greater understanding. Gawande wrote:

"First, all aspects of life are conducted in the same place and under the same central authority. Second, each phase of the member's daily activity is carried on in the immediate company of a large batch of others, all of whom are treated alike and required to do the same thing together. Third, all phases of the day's activities are tightly scheduled, with one activity leading at a prearranged time into the next, the whole sequence of activities being imposed from above by a system of explicit formal rulings and a body of officilas. Finally, the various enforced activities are brought together into a single plan purportedly to fulfill the officials aims of the institution."

Gawande's example made nursing homes seem similar to kindergarten. The problem being that adults have awareness, beliefs, worries, and desires that far exceed those of children. Structuring nursing home residents' lives as if they were in a children's classroom stripped them of the choice to author their lives. It stripped them of the experience of living. Instead of removing experiences from life, nursing homes should facilitate discussions with residents and families. The wants, needs, and desires of the resident and their family should be embraced. The care providers, family, and residents should have discussions about how the resident wants to live out the remainder of their days. The discussion should include how to make the resident feel most at home, while still keeping them safe and healthy.

Gawande wrote of the riveting journey of, Keren Brown Wilson, one of the originators behind the concept of assisted living facilities. Assisted living facilities are different than nursing homes. To summarize the differences in a manner, nursing homes offer more medical care and personal assistance but less freedom. Assisted living facilities, on the other hand, offer less medical care but emphasize residents' independence. Keren Brown Wilson envisioned an environment in which the care providers saw the assisted living facility as the residents' home. The outcome, whether purposeful or not, was a shift patient-provider relationship dynamics. Wilson's residents had more control over their lives. Some of the autonomy came with increased risk; and the willingness of Wilson to facilitate autonomy depsite the risk surprised me. I was surprised because I had fallen into the trap of valuing safety and precaution above all else. Closely governing diets and prescription intake seemed absolutely necessary, and not doing so seemed tremendously dangerous from my point of view. As I read further and saw the meaning behind the changes that Wilson had accomplished, my ideals shifted. I understood that 'healthy' patients can still be unhealthy. I can choose whether I adhere to a healthy diet and take my prescriptions as instructed, and assisted living residents shoudl be afforded the same authority. If a resident wanted to try walking without their cane, they should be allowed, of course within reason. Wilson believed in providing a place where residents retained the autonomy and privacy of living in their own homes. Wilson allowed residents to refuse guideline that served safety and convenience purposes. Wilson's residents were more satisfied, their health was maintained, their physical and cognitive functioning improved, incidence of major depression decreased, and the cost for those receiving government support saw a 20% decrease when compared to nursing home costs. Gawande asked a question that each person should investigate. The question is...what makes life worth living? I've asked myself this question, and I'm going to continue to ask this question, year after year...month after month. The answer may change. The answer may be simple, or it may be convoluted.