About once a year a book has me on the edge of the seat and really challenged - Being Mortal – illness, medicine and what matters in the end seems to be this year’s book. It’s written by a rather special doctor of Indian origin who has been working in US hospitals and also writing for The New Yorker …. Atul Gawande
Initially it presents a rather harrowing description of what the onset of age does to our body – and how modern medicine responds….with more and more sophisticated (and expensive) treatment – increasingly in hospital. The deservedly acclaimed film “One Flew Over the Cuckoo’s Nest” may be about patients in a “mental home” but the treatment which audiences saw exactly 40 years ago is all too evident in all institutions these days…..
In my parents’ generation people tended to die a few years after retirement but a mix of factors (eg the decline of manufacturing industry and medical advances) has added at least 10 years to “life expectation” in Europe and North America.
That led to political panics a decade or so ago about the fiscal burden of pensions (assuaged to an extent by the breaking of social promises and contracts) and the constant climb in health costs then led to campaigns to get us living more healthily. But the public continue to expect the best medical treatment and - when that fails - institutional care of “the elderly” who tend these days to be living on their own hundreds of miles/kilometres away from sons and daughters….
Gawande paints an ugly picture of the suddenness with which people in their 70s can fall from autonomy to institutional dependence and regimentation and rightly accuses us all of failing to prepare for this.
I am as guilty as the next although a little voice has been encouraging me this past couple of years to “copy and save” articles and papers about ageing - on which I will draw for my next post
The heroes in Gawande’s story are some mavericks who couldn’t accept the regimentation; had a passionately-held vision of an alternative system which allowed people to assert the independence they had come to expect in their own homes; and had the guts, skills and perseverance to build examples of such alternatives whose results were not only cheaper but led to a better quality of life…..By 2010 the number of residents of such small complexes which spread across America was approaching the number in nursing homes. But then, Gawande tells us
“a distressing thing happened – the concept of assisted living became so popular that developers began slapping the name on just about anything. The idea mutated from a radical alternative to nursing homes into a menagerie of watered-down versions with fewer services….concerns about safety increasingly limited what people could have in their apartments and defined ever more stringent conditions which would trigger discharge to a nursing home. The language of medicine, with its priorities of safety and survival was taking over again” (p101)
And the boards running such places wanted the profits which come from a larger scale than the original concept
I was reminded me of the “sheltered accommodation” my mother chose to live in between the ages of 85 and 95 – cooking and shopping for herself. I checked and there it was – a complex of only seven flats – part of a charity which has more than 100 such places in the UK…So all is not lost!!!
But the importance of “autonomy” – whether in company structures or the way we live our lives……- is still hidden from most of us.......