Fact #1: Lacking some significant medical breakthroughs, if you’re reading this sometime in 2024, you’re probably going to die within a single-digit number of decades.
Fact #2: The entire medical profession has been incredibly well-trained and well-equipped to keep us from dying.
Combining Fact #1 with Fact #2 leads to a bit of conflict and unease in our society.
But first, let’s rewind the clock a generation or two and look at how we got here.
Prior to the 1930s, families provided the care and support for their elderly family members until their death. If you didn’t have a family to support you, then you had a couple of different options.
Option #1 is the best choice: have bags and bags of money lying around to hire help in old age. The folks fitting that profile were predictably well taken care of. Option #2 was considerably more bleak. This involved being placed in an asylum/poorhouse with a whole bunch of other people with no family to care for them. By all accounts, those were some dismal and dehumanizing places to live.
In a nifty confluence of events, at roughly the same time that Social Security rolled out and started providing financial support to those seniors who had no family nor funds to support them in their old age, the medical advances developed during World War II started to lap up on our shores. Old age quickly moved from being merely another stage of life with a predictably precipitous end and came to be viewed more as a medical problem that could be fixed with our newfound technologies like antibiotics and surgical techniques. The solution for old age was pretty obvious: put old people in hospitals.
That approach worked for a couple of years, but then hospitals started to realize that their beds were filling up with people who weren’t dying nor getting well. This led to a couple different efforts to addressed the problem. Effort #1 was that in the 1950s and into the 1960s, the federal government dumped billions of dollars into the construction of new hospitals across the nation. But as it became clear that hospitals couldn’t keep up with demand for their beds, in the late ’50s and into the early ’60s, a new form of care came into being: the nursing home.
As the name implies, nursing homes were designed to provide care to the sick and elderly. The structure was built around the idea of the patient being, well, a patient. The operating and business practices of nursing homes were designed to promote the efficiency of the facility and not necessarily caring so much about the needs and desires of the patients.
Enter a new idea: the assisted living facility. Assisted living, at its best, tries to hand the autonomy of life decisions back to the resident in terms of what time they shower, what time they wake up, what time they go to bed, what they eat, when they eat, who they have over as visitors and/or lovers, etc. All this just happens to occur where skilled nursing is available just down the hall.
Preserving that sense of self and independence is, in my mind, the guiding star of what medicine should be aiming to provide and what I should be asking of my health care providers now that I am, ahem… old.
With medical science now able to prolong life far beyond what had been dreamt of in years past, the question now becomes one of when scientific and technological prowess need to recognize human mortality. As Gawande points out, he was trained to fix problems. If you have cancer, do some surgery. Do some chemo. Do some radiation. And if those remedies cause some cascading series of issues and traumas, those are to be dealt with those as they come. The medical profession has gotten so good at addressing individual medical problems that human existence can get whittled down to the point where people are kept alive without actually living.
Having arrived at the ripe age of nearly 51 years old now, my takeaway from this book is that we all need to be thinking about what it is we want from our medical care. What is it that we are willing to give up to get to a certain outcome? If what gives life meaning is stripped away and a person is left as a breathing stump of a human in a bed, have we really made any progress?
That’s a trick question.
Gawande’s point is that the question above doesn’t have a single answer. The answer varies from one person to another to another. And the range of answers varies significantly. For some who are facing rounds of chemo and surgery, they just want to make it out of that process with the ability to watch football on TV and eat ice cream. That’s enough for them. For others, that outcome sounds horrific and not worth the trade.
Those conversations, as awkward as they might be, are the path forward that allows patients, families, caregivers, and doctors the ability to determine when to press ahead with treatments and when to say “What do you want out of your remaining days, however many they might be?”.

