The old saying goes that once you have faced death, you can truly live. Trite but true. Of course we spend much of our lives taking very good care to see that we remain as healthy as possible for as long as possible, but the reality is still that we are going to die.
Atul Gawande, a medical doctor himself, wrestles profoundly but personally with the dilemma of submitting ourselves to medical systems and mindsets that have been geared to prolonging life at all costs (a great strategy that has us living longer than ever before) but also coming to grips with the fact that at some point the inventions and interventions will no longer work and may actually increase suffering. In this pivotal moment, the important thing to remember is that we are mortal and the choices we make at the end of life need to be more around the quality of life remaining, even if those choices shorten life and involve refusing treatments that are available. The goal should not be a good death, but a good life to the very end. And that will look very different in each unique person, family, and situation. Gawande doesn’t offer solutions, just discusses the issues in a very accessible format.
Gawande talks about nursing homes where the focus on safety can prevent a full and dignified assistance of individual needs. He points out the high value in hospice care as an alternative to further treatment, if that is available and appropriate. Unfortunately hospice is sometimes seen as a giving up or as a failure or weakness once everything else has been tried, rather than a positive alternative to being cared for in the final chapter that leads to fullness of life till the end. Useful and engaging, the stories he tells in the book give a dignified view of those who are in the process of giving up their independence to old age or illness. His models of care focus on living a meaningful life.
Through gently storytelling, the book is also very useful in walking the reader through difficult conversations, accepting hard truths, whether patient or carer. The final chapter of our lives may have a fullness and a richness we could never have imagined, if the right choices are made. That chapter might include sharing memories, passing on wisdom and keepsakes, settling relationships, establishing legacies, making peace with God, and ensuring that those left behind will be ok. “As people become aware of the finitude of their life, they do not ask for much. They do not seek more riches. They do not seek more power. They ask only to be permitted, insofar as possible, to keep shaping the story of their life in the world–to make choices and sustain connection to others according to their own priorities.”