Being Mortal - Book Summary

Unlock the secret of accepting our mortality

There are two guarantees in life — death and taxes. While we reluctantly acquiesce to sharing our earnings with the government, accepting our impending mortality seems a far more daunting task. Isn't it about time we addressed this?

Medical advancements today push the boundaries of life expectancy further than ever before. But this blessing of longevity carries with it a darker consequence — the process of dying no longer a quick transition, but a painfully prolonged decline. As individuals, as communities, as a civilization, it's high time we confront this stark reality. We need to explore ways of transforming our journey towards the end from a dreaded ordeal into a journey marked by dignity and understanding.

In this narrative, you'll delve into the following insights:

— the profound importance of maintaining dignity until our final breath;

— the urgent need for our nursing homes to adopt a more compassionate and human-centric approach; and

— the necessity to ponder on our mortality today in order to make our eventual passing a more bearable, peaceful process.

The inevitable decline of aging and disease brings increased dependency

No one likes to dwell on the prospect of illness or death — it's simply not pleasant. Yet, these are grim inevitabilities we all will encounter as we journey through life — both on a personal level as our bodies wear down with time, and as an empathetic observer witnessing the decline of our loved ones. The knowledge of its inevitability makes it crucial to open dialogues about death and the process of dying.

As we grow older, our bodies inevitably begin to slow down. Vital organs lose their vigour, while bones, muscles, and teeth undergo depletion. Meanwhile, blood vessels and joints stiffen with age. The cumulative effect of these changes put significant strain on the heart, forcing it to work harder to keep blood circulation steady. As a result, high blood pressure becomes a common ailment among the elderly.

Our cognitive abilities are not exempt from this deterioration — as our brain shrinks, we might be confronted with conditions like dementia.

As the body's numerous systems grapple with these changes, our susceptibility to injuries and illnesses escalates, and our ability to self-sustain wanes. This vulnerability is evident in the increasing number of elderly people experiencing severe falls due to muscle weakness. In the U.S., approximately 350,000 individuals succumb to broken hips annually because of weakened muscle mass.

This irrevocable decline of physical abilities inevitably diminishes our ability to live independently. Simple day-to-day tasks, such as grocery shopping or even using the restroom, become Herculean undertakings.

At this juncture, many of us will need to rely heavily on family members or professional caregivers, potentially leading to the prospect of spending our final years in a medical facility or a nursing home.

The harsh realities that come with aging and disease are not easy to swallow, let alone accept. Therefore, it's crucial that we confront these truths head-on and explore ways to mitigate the pain and discomfort associated with this inevitable part of life.

The rise of institutionalized care: The modern face of aging and dying

With the advent of modern medicine, our lifespans have been stretched to lengths unimagined in the past. Diseases that would have swiftly claimed lives post-50 in bygone eras are now manageable, thanks to medical advancements slowing down the body's aging and pushing death to a later date.

Such progress has sparked a seismic shift in the world's demographics. In the past 200 years, the proportion of Americans over the age of 65 has surged from a mere 2% to a substantial 14%. Other countries like Germany, Italy, and Japan observe an even higher percentile, with seniors constituting a whopping 20% of the population. It's an interesting paradox: our success in increasing longevity has radically changed the ways in which we age and eventually die.

Historically, families often lived together under one roof or at least in close vicinity to one another. As parents grew older and frailer, their children would assume the role of caregivers. This arrangement ensured the elderly could live out their final days in familiar surroundings, continuing to participate in everyday family life.

However, the individuals unfortunate enough to not have family support would end up spending their final days in squalid poorhouses.

Fast forward to modern times, where the responsibility of caring for the aged and the ill has largely shifted onto healthcare professionals. Consider this: In 1945, the majority of US citizens died at home. By the 1980s, a starkly contrasting picture emerged — a paltry 17% of the population met their end in their own homes. Today, most deaths transpire within the sterile confines of hospitals and care homes. What provoked such a transformative shift?

Geographical dispersion of families is one key factor. Adult children, often living a considerable distance from their parents, find it challenging to open their homes and take up the daunting task of full-time caregiving.

Fortunately, contemporary hospitals and nursing homes, a far cry from the hellish poorhouses of the past, offer satisfactory medical attention within clean, safe environments.

But, despite their efficacy in offering medical support, these institutions often fall short in understanding and catering to our deeper emotional and psychological needs as we approach the final curtain of our lives.

The universal longing for autonomy transcends age and illness

In the bloom of our youth, we relish the unrestricted freedom that comes with independence. Living on our own terms, devoid of interference, is a privilege we come to cherish.

But, as a universal truth, this complete independence is not everlasting. With advancing age or illness, we need to concede to the limitations dictated by our declining physical and mental abilities. Yet, this surrender does not equate to relinquishing the values and principles that have sculpted our lives.

Be it in youth or old age, our desire for autonomy remains steadfast, coupled with the need to feel that our lives continue to bear meaning and significance. Even as advancing years strip us of certain abilities, we yearn to maintain some measure of independence.

For instance, if you're passionate about cooking, but the toll of aging impedes your ability to shop for groceries, you'd prefer assistance with shopping rather than forsaking cooking altogether.

As we inch closer to the end of our mortal journey, our perspective on life undergoes profound transformations. Simple everyday pleasures often replace the quest for novelty and excitement. Simultaneously, our connections with family and friends take on greater importance.

Stanford psychologist Laura Carsten illustrates this shift in priorities through a unique study. Participants were given a set of cards, each describing a potential acquaintance — their mother, their favourite author, and so forth. They were then asked to determine who among them they would prefer to spend half an hour with.

Interestingly, while younger participants veered towards spending time with fascinating new people, elderly participants and those living with HIV opted to connect more with their close family and friends.

Despite the promise of a more relaxed and content state of being, aging is often viewed with apprehension. As we will explore in the upcoming sections, the inadequacy of medical institutions in addressing the emotional and psychological needs of seniors is a significant contributor to this fear.

The bittersweet truth: The system's struggle to uphold the independence and dignity of the elderly

When envisioning life in an old age home, we often conjure up images of monotonous spaces steeped in gloom and desolation — a stereotype that sadly mirrors reality. Loneliness and ennui have become the silent companions of many elderly individuals.

Nursing homes and intensive care units, while providing essential care, often operate on a rigid schedule that undermines an individual's autonomy. Residents, who have previously enjoyed a lifetime of independence, suddenly find themselves on a fixed timetable with little to no personal privacy.

It's simpler for caregivers to dictate decisions for the elderly, rather than guiding them in making their own choices. Take the example of dressing up — while a resident might be able to dress themselves with a bit of help, it's more time-efficient for the nurse to do it instead. Although this may streamline the caregiving process, it leaves residents feeling helpless and marginalized.

While nursing homes shine in offering physical care and maintaining safety standards, they often fall short in creating an environment where residents feel valued and at home.

Despite doctors and caregivers dutifully providing basic medical care — hygiene, feeding, dressing, and medication management — the need for emotional acknowledgment and understanding remains largely unmet.

Understaffing in these institutions aggravates this issue. The severe dearth of geriatricians — medical professionals specializing in the healthcare of older adults — is a chronic problem nursing homes face. With their workload already immense, doctors and nurses struggle to spare extra time to make their patients feel more valued.

Currently, the family stands as the only viable alternative to this institutionalized indifference. However, handling the care needs of older family members or the sick is a demanding task, and even the most devoted of families may falter in making the best decisions on their behalf.

The elusive quest for longevity: Prolonging life at the cost of suffering

A staggering 25% of US healthcare costs are funneled into treatments for patients in the twilight year of their lives — a group that constitutes just 5% of all patients. While some of these interventions indeed prove beneficial, many serve as futile efforts to extend an inevitable end, inflicting more harm than good in the process.

When it comes to selecting treatments, both patients and doctors often fall prey to illusions of hope. Despite facing overwhelmingly adverse odds, patients and their families invariably cling to the faint hope of a miraculous recovery that is more fantasy than reality.

Ironically, doctors themselves contribute to the perpetuation of these unrealistic expectations. Hesitant to shatter the hopes of their patients and their families, they often endorse this misplaced optimism. In fact, over 40% of oncologists confess to recommending treatments they doubted would yield positive results.

Consequently, terminally ill patients often opt for aggressive treatment modalities. These interventions, however, often result in debilitating side-effects — extreme fatigue, incapacitating nausea — compromising the patient's immediate well-being for the slim chance of gaining extra time.

It seems we place a higher premium on prolonging life, even if it means compromising its quality. Ultimately, however, meaningful and enjoyable final days could offer more solace than the relentless anxiety of trying to stretch out our time on earth.

The American Coping with Cancer project lends weight to this perspective. The study revealed that terminally ill cancer patients who chose to halt intensive treatment and spend their final days at home or in a hospice experienced a significantly higher quality of life during their last weeks, compared to those admitted to intensive care units.

Terminal illnesses, such as cancer, as well as the natural diseases accompanying old age, pose pressing questions for patients, their families, and doctors alike. When is it time to fight? When is it time to accept the inevitable? And, perhaps most importantly, how can we ensure a better departure from life?

Reimagining aging and mortality: Balancing independence with a meaningful existence

Evidently, contemporary healthcare systems falter in catering to the unique needs and desires of those on the brink of death. To age gracefully and to die with dignity, we need to prioritize services that respect personal autonomy while providing empathetic assistance and guidance when necessary.

Assisted living serves as one such model that aligns with this vision. It provides the same level of care as traditional nursing homes but without their regimented structure.

Residents in assisted living facilities are allocated their own spaces where they can cultivate a genuine sense of "home". They have the freedom to determine how they want to spend their time, assess the risks they are willing to accept, and decide how much assistance they require.

While the author commends assisted living, it's also crucial to consider innovative approaches to senior living.

We can take inspiration from a nursing home in New York that aimed to uplift the spirits of its residents by creating a garden. In addition to this, they arranged regular visits from local kindergarten students and even introduced a host of animal companions — two dogs, four cats, and a hundred birds!

Remarkably, within two years, the average number of prescriptions per resident had plummeted to half that of conventional nursing homes, and the annual mortality rate had decreased by 15%. How did this happen?

The responsibility of nurturing the children, animals, and plants infused the residents' lives with a newfound joy and purpose. This offered them a compelling reason to carry on living.

The scope and quality of hospice care services need to be expanded and enhanced as well. For those with terminal illnesses, their end-of-life experiences are fundamentally shaped by the hospice care they receive. Instead of centering on medical treatment, nurses, doctors, and social workers should strive to help people live their remaining days to the fullest.

As we devise fresh strategies to navigate aging and illness, honest communication of our desires and needs to our doctors and families becomes increasingly vital.

A delicate balance: The role of doctors in guiding patients nearing the end of life

The dynamics between a doctor and their patient can be complex, especially when dealing with terminal illness. Doctors, after all, are as human as their patients and they constantly grapple with the challenging duality of maintaining professional detachment while expressing genuine compassion.

However, to truly help those suffering from serious illnesses, doctors need to find a delicate equilibrium between these two extremes.

Physicians should steer clear of adopting an authoritarian stance, where they dictate which treatments patients should undergo. Equally, they should avoid taking a purely informative role, leaving patients to navigate their care in a state of overwhelm.

The optimal approach is a balanced one. Doctors should furnish all necessary information, discuss realistic options, discover what matters most to their patients, and finally, offer their personal perspective.

For instance, doctors could ask terminally ill patients about the activities that hold the most significance for them — maybe it's playing tennis, maybe it's spending time with their children. The doctor could then provide details on the treatment options that would best allow the patient to continue engaging in these activities for the longest time possible, even if it might potentially reduce their overall lifespan.

In severe cases, the idea of assisted dying should be permissible for discussion. Though the topic is fraught with controversy, it's essential that doctors be open to engaging in conversations about assisted death for those experiencing unbearable pain.

Although actively aiding in a patient's death is illegal in many countries, offering medical advice on the topic could help patients prioritize their desires and feelings.

With the processes of aging and death now intricately entwined with medical involvement, it's critical that healthcare professionals enhance their listening and communication abilities. By doing so, they can better cater to their patients' needs, offering the guidance and support that are so crucial during this sensitive phase of life.

Embracing the inevitable: The importance of candid conversations about age, illness, and death

We often tend to avoid contemplating aging and death — whether it's our own or that of our loved ones. As a result, we usually only face these harsh realities when it's too late, hurriedly making decisions under pressure and depriving ourselves of a dignified farewell.

Therefore, it's crucial to engage in open discussions about age-related issues and illness with our families and friends. For instance, considering the compromises you're willing to make when illness strikes or during your final moments. To make this more relatable, ponder the following questions: What will be your utmost priorities in your final hours? What makes life worth living for you?

There's no pressure to immediately answer these questions; the mere act of discussing them can provide invaluable clarity on how you envision your twilight years and your departure from this world. These conversations become particularly vital when you're no longer capable of making decisions for yourself, and others are left to make them on your behalf.

Moreover, confronting the end of your life at an early stage can be empowering. By facing your hopes and fears and accepting your mortality, you maintain a sense of authorship over your life until the very end.

Embracing the inevitability of death empowers you to choose your "role in death", enabling you to control what legacy you leave behind and how you'll be remembered.

For instance, when the author's daughter's piano teacher was in the final stages of terminal cancer, she mustered her remaining strength to provide each of her students one last piano lesson. This ensured that her guidance as a teacher would live on through her students' music.

By candidly confronting aging, disease, and death, we can enable individuals, families, and societies to make mortality a less harrowing experience and perhaps even imbue it with a sense of purpose and meaning.

In conclusion

Facing the inevitability of death may be challenging, but it's a universal part of life. The good news is, we have our entire lives to prepare for this unavoidable eventuality. Such preparation entails reflecting on what truly matters to us and communicating these values to our loved ones and healthcare providers. Moreover, we should strive to enhance the quality of life in nursing homes, ensuring that they become more fulfilling environments for residents.