Finding What is Important: Atul Gawande’s Being Mortal

In his letter, later titled “On the Shortness of Life”, the philosopher Seneca chastises his friend Paulinus for living “as if you were destined to live forever, no thought of your frailty ever enters your head, of how much time has already gone by you take no heed. You squander time as if you drew from a full and abundant supply, though all the while that day which you bestow on some person or thing is perhaps your last.” This reprimand was intended to inoculate Paulinus against the dangerous habit his culture had, and my culture has, of tricking ourselves into believing death does not happen to us.

Seneca, and his fellow Stoics, were worried that if we were unwilling to reflect on our own obliteration, we would not sufficiently treasure our lives while we still have them. The Stoics’ prescription was to carefully consider our last breath, to think of ourselves greeting death, and to realise what would be important at that final moment of existence. When you can see no more, how much will you value your last glimpse of a loved one? When there are no more sounds, how much will you value a single note of music? When there is no more air, how much will you value that last breath?

When you can see no more, how much will you value your last glimpse of a loved one?

I strongly suspect Atul Gawande is no stranger to Seneca, as his Being Mortal threads the meditations of Stoicism with his many years experience as a surgeon. Gawande’s focus however, is not on that moment of death, but the months and days approaching it. Being Mortal begins as a reflection on Gawande’s interactions with the infirm, the terminally ill, and the aged. He is disturbed by his growing awareness that the modern health system, of which he is a part, is embarked on a prolonged drive to sustain the life of patients, and that this drive appears to come at the cost of patient happiness. The most vivid example is the ability of mechanical life support to keep a patient physically alive, at least to the point that oxygen is still being circulated to the brain, even when consciousness will never be regained.

At the heart of Being Mortal is a surprisingly simple extension of that Stoic question: in the last days of your life what will be most important to you? Is it being at home? Being present at someone’s birthday? Or simply being able to hold someone’s hand? Such thoughts are seldom considered. Or, at least I had not previously given such things thought before encountering Gawande’s book. Nor for that matter had I considered how my parents might face their own ends, or I my own. Death is after all not a frequent topic in my culture, and I see now we suffer for it.

That this self-imposed taboo extends even to doctors’ conversations with the dying is, on reflection, absurd. Gawande encounters, in himself and in his peers, a deep unwillingness, even fear, to be honest with patients’ about their own mortality. He describes the verbal and mental acrobatics medical professionals put themselves through to avoid telling someone that there is no more to be done and their life will soon end. Instead these professionals will embrace what Gawande realises we have come to expect from the medical system: a continued stream of medical procedures aimed at extending increasingly painful lives. Each intervention becomes more desperate, and more hopeless, than the last. It is agonising to read.

Gawande encounters, in himself and in his peers, a deep unwillingness, even fear, to be honest with patients’ about their own mortality.

I was captivated by Being Mortal, as its implications thundered towards me with each turn of the page, and yet because of the agony it held I had trouble finishing it. I would pick it up only with a heavy heart, dreading before the first words had left their pages the confronting realisations that Gawande so deftly laid before me. On numerous occasions I considered returning Being Mortal to the shelves, and ridding myself of the deep discomfort it created in my life. I didn’t of course. I couldn’t.

Gawande’s triumph as a writer is that no matter how deep the sense of discomfort he creates, Being Mortal must be read. At night, with fatigue dogging the edges of my vision I would read in bed, overcome with my own mortality and that of those around me, yet unable to put it down. Unable to sleep because I needed so desperately to understand Gawande’s book.

I couldn’t stop reading Being Mortal, no matter how it made me feel, because I knew Gawande was right. We have allowed ourselves, wrapped in our cocoons of modern life, to become afraid of death. We have allowed ourselves to believe that there is no such thing as a good death. We have allowed ourselves to believe that a good life is a long life, and that what is important is continuing to breathe. The revelation of Being Mortal is the same one that Seneca tried to inspire in Paulinus: life is to be lived for all that it is; each day treasured and then left without remorse; and our deaths met with dignity.

We, collectively, put so much effort into prolonging the lives of the dying that we fail to see that we have taken away people’s reason for living.

life is to be lived for all that it is; each day treasured and then left without remorse; and our deaths met with dignity.

In his very last days my grandfather, by then wobbly on his feet, could be seen walking in the garden of the hospice, his tie still perfectly knotted, puffing contentedly on a cigar. I think he knew he was not long for this world, yet at that moment, what was important for him was to be able to smoke one last cigar with the sun on his face. The next day he didn’t put on a tie, I think that’s when my father knew his was dying. He died the next morning. I didn’t know what it was then, but I think he died a good death.

I have been thinking frequently of Gawande these past days. My grandmother, my last surviving grandparent, is dying. I find myself again in need of the lessons in Being Mortal.

My grandmother’s body is frail, she has never really recovered from her last fall, but it is her mind that is slowly going. She remembers her childhood, her parents, and her children, but the present eludes her. She takes time to recognise me, and when she does it is often me from another time. The one thing that remains fixed for her has been her great-granddaughter, her first great-grandchild, who was born this week. She forgets who the child’s parents are, congratulating my parents rather than my brother and his wife, but the child is real for her. She is here, another generation forms my grandmother’s legacy. Because of Gawande, because of Being Mortal, it is clear to me that this has been what is important for my grandmother. I have not sought to correct her temporal confusions, nor fixated on her health, but instead encouraged her to think on this small new life born into a family she created. She lives in between time now, the only present is the knowledge of her great-granddaughter. She will die soon, she has lived to do what was important to her. We will not prolong her life against her wishes, we will not deny her the final dignity. When she goes I will mourn her, but I will not dwell on her death. She lived well, and in balance with that life, will be her death.

If someone in your life is approaching the end of their years, please find a copy of this book, it will help you find peace in turmoil. If nothing else it will remind you that where they now go, you will soon follow, and that you must enjoy now what they are already losing. Being Mortal was written for me. It was written for you. It was written for all of us, because we must all grapple with death.

-H

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