The exit strategy

Lead review

Perhaps we should reform the medical profession by keeping the young and immortal out of it. Let’s bar medical school entry till age 50: Presumably that would fix our present bizarre disconnect between the army of doctors bent on preserving life and the tiny band able to accept death. Doctors would come equipped with the age-bred wisdom to understand the continuum, and they would demand a health care system that did likewise.

That’s not happening any time soon. As things stand, though, at least we have the bittersweet pleasure of watching the occasional thoughtful defection from the mighty army to the little band.

Dr Atul Gawande, possibly the most articulate defector yet, has made his considerable reputation primarily as a fix-it man. As a Harvard surgeon he patches up organs; as a longtime writer for The New Yorker he has both described and prescribed for many of our profession’s troubles. The recent widespread enthusiasm for checklists to minimise medical errors can be traced more or less directly to his pen.

In Being Mortal: And What Matters in the End, Gawande (heading for 50) has turned his attention to mortality, otherwise known as the one big thing in medicine that cannot be fixed. In fact, the better doctors perform, the older, more enfeebled and more convincingly mortal our patients become. And someone should figure out how to take better care of all of them soon, because their friends, neighbours and children are at their wits’ end.

It is one thing to understand this helplessness, as most young doctors do, by watching the trials of patients and their families; as an observer, Gawande has visited this territory before. It is quite another thing to be socked in the gut by age and infirmity unfolding in one’s own family — an experience that has to be the world’s finest postgraduate medical education.

Gawande completed that curriculum in three courses: his grandfather’s extraordinarily long and atypically happy old age, his wife’s grandmother’s extremely long and typically unhappy old age, and his own father’s struggle with age and illness.

The grandfather lived to almost 110 years old in a small Indian village, surrounded by family members who cared for him and catered to his every whim. All was not idyllic — a patriarch’s prolonged survival can certainly play havoc with everyone’s financial expectations — but his was the kind of empowered aging to which most aspire.

Instead, what they usually get is the slow entrapment experienced by Gawande’s grandmother-in-law, a self-sufficient New Englander whose horizons were increasingly hemmed in by the terrible dictates of ‘safety’. She was not safe to live alone, not safe to drive, not safe to manage her own finances — she was not safe to live at all, really, yet condemned to live on. A balance between a reasonably risk-free old age and one worth living is surpassingly difficult to devise; it is the rare institution or family that manages it, as Gawande’s extensive reporting makes clear.

But in his father’s case, it was disease, not age, that ultimately forced a careful consideration of the meanings of ‘life’. Gawande’s father, a surgeon still operating in his 70s, developed a malignant tumor near the top of his spinal cord, inexorable and incurable. His surgeon’s hands were the first to go.

Gawande’s description of his father’s slow process of detaching from a familiar and beloved life — a determined, heartbreaking effort, never completely successful — forms the philosophical nucleus of the book’s intertwined essays on the meaning of health care when time is short. Ultimately, the considerations are the same whether the patient is young with a terminal illness or old and failing: It should be all about setting discrete goals and maximising well-being, much less about maximising survival as such.

A few details from these essays, only two of which were previously published in The New Yorker, are particularly striking. One is the priceless image of the Harvard surgeon sitting in his parents’ home in small-town Ohio, waiting with very low expectations for whatever version of a hospice nurse the local agency might provide. When the nurse arrived, Gawande recounts with chagrin, she ‘blew me away’ — a consummate professional, she transformed his father’s last days.

Another is the author’s palpable enthusiasm as he learns that many of the most difficult conversations doctors should have with their patients can be initiated with only a few questions. (What are your fears? Your hopes? The trade-offs you will and will not make?) One suspects a new checklist may be in the offing.

Finally, there is his quiet admission: “No one really ever has control.” That’s quite a statement coming from a surgeon, for whom control is the sine qua non of all professional endeavor, and from an essayist who has proposed a host of ways to control the loose ends of medicine. If the Cheesecake Factory restaurant chain can provide quality food on a giant scale, Gawande wrote in 2012, then perhaps doctors should adapt its corporate tools to dispense large-scale quality-controlled health.

This book is an acknowledgment that serenity and well-being actually cannot be dished up cafeteria-style — and that sometimes the only sure way to gain control is first to relinquish it, whether to a bad disease, a dying patient or the constraints of a finite life span.