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.......
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