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Atul Gawande’s Being Mortal is a wonderful exposition of the current status of end-of-life care in the United States. Old age and dying are difficult subjects, but Gawande tackles them with a great sense of honest and optimistic realism. Using a mixture of personal anecdotes and expert research, Gawande charts the development of nursing homes, assisted living facilities, and the like, all along the way identifying the many ways in which end-of-life care has fallen short. The current way of caring for the elderly is far too controlling, clinical, and dishonest.
The Hippocratic Oath that every doctor takes states to first do no harm, but geriatric care has devolved to breaking this oath by throwing experimental treatments at patients and keeping them dependent and unhappy. The United States and many other developing countries are experiencing a demographic transition that must be addressed comprehensively if we are going to thrive in the 21st century. With health scare spending skyrocketing and the Baby Boomers transitioning into retirement, America faces a both a great challenge and a great opportunity to reform end-of-life care policy and move it towards success and sustainability.
Community-based models of assisted living, realistic yet personal end-of life care, and an overhaul of Medicare and Social Security are all major steps that we as a nation must take in order to ensure the health and happiness of our elderly population. Rugged individualism is as much a part of the American psyche as hot dogs, baseball, or reality television. From the Bill of Rights to Manifest Destiny, we have always placed a greater emphasis on the individual rather than the collective.
This has not been without its consequences, of course, but it is a markedly American characteristic that most if not all citizens experience or posses to a degree. As it stands, our end-of-life care policies do not adequately reflect and encourage the natural desire for independence and freedom. Nowhere more so than the nursing home does the philosophy of medicine, which is to fix a problem, collide with the philosophy of liberty. Nursing homes are notorious in particular for policies that are much too controlling of their patients’ lifestyles, from denying them simple pleasures like alcohol, cigarettes, and the foods they like, to eliminating any sense of privacy.
As Gawande points out, however, nursing homes are not to be blamed for this, because it is simply their natural response to try and help their patients by micromanaging their daily activities. Thought their intentions are good, nursing homes make their patients feel dependent and controlled, leading to a lower quality of life at a time when life should be the highest quality it can be. The better model of care is that of Keren Brown Wilson at Park Place in Portland, Oregon. Assisted living is the best way to care for the elderly because it creates a delicate balance between care and independence. Of course, the term has lost its meaning in recent years as companies slap it on facilities without any true metric to determine whether or not it is a true assisted-living facility. A national standard for assisted living facilities is needed to clarify for the consumer which facilities will be best for them or their loved ones. Medicine has come a long way, and treatments and technologies only advance everyday, but most doctors and patients facing terminal illnesses, especially when dealing with the elderly, operate under an illusory premise.
Experimental drugs and operations can actually decrease a patient’s quality of life, and no one would choose to die in a hospital bed if they had the option to do so in the comfort and familiarity of their home with family and friends instead. In this way, medicine needs to be more honest in end-of-life care. Many patients will be willing to fight their disease in any way they can, but for many others, when presented with all the facts and figures, will choose to die peacefully and on their own terms. Neither choice is “better”, but the ability to choose is an absolute must.
The biggest policy implications for end-of-life care come from the staggering financial costs, which have increased exponentially in the past several decades. As Gawande writes, 25 percent of all Medicare spending is for the 5 percent of patients who are in their final year of life. United States health care spending hovers around 17% of GDP, according to the World Bank’s annual report. The major burden falls onto states, which are faced with tough budgetary choices as demand and costs rise. Medicare and Social Security, the two most prevalent programs for the elderly in the United States, combine to make up 40 percent of federal spending (The Hill). Both programs are likely to face insolvency by 2030, and if you ask any Millennial they will tell you that they do not expect to ever see a Social Security check. Both programs are in need of serious reform, an implication easily inferred from Being Mortal. The biggest goal of end-of-life care should be helping patients age and die with the maximum amounts of independence, dignity, and peace. Unfortunately, this is an expensive task, but as a society we must prioritize care for the elderly.
Ultimately, Being Mortal provides profound insight into end-of-life care through Gawande’s unique perspective as a surgeon and the son of Hindu Indians. The policy implications are clear. First, community-based assisted living facilities should be the norm, not the exception. Second, doctors should be forthcoming and honest with patients and their families about the likelihood of success, focusing on doing no harm and helping the patient to live the best life as possible, not necessarily to live as long as possible. Finally, federal and state assistance programs need to be saved for future generations, because they are a crucial part of the end-of-life care system.
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