The nearness of death being a certainty: Atul Gawande's book, Being Mortal

Being Mortal, by Atul Gawande. Metropolitan Books, New York 2014.

Being Mortal is a complicated book to summarize. It's a good book. Gawande concentrates on the last period of our lives, when we or our legal surrogates decide on how we live those final days and months. We may be either in failing health because of old age, or are in the last stages of a painful terminal disease, such as a cancer. The medical and life decisions to be made are often excruciating. Either way, those last days are often spent in suffering and torment. The nearness of death is a certainty.

Gawande focuses the first part of the book on how the elderly live their lives as they become weaker. Usually, it's in an institution, an assisted living center where the staff follows an economical and efficient regimen. Medicines are dispensed, rooms and "residents" or "patients" are checked, meals are served, and healthy approved activities are organized all on a schedule decreed by management. All of this is at great financial expense, but worse still is that many of the elderly are deprived of what they want most -- to live meaningful lives doing the things they enjoy doing, on their own schedule. My father-in-law bitterly resented his years in a highly rated, comfortable assisted living center. He hated the loss of his privacy (staff nurses would knock on his room door once and immediately unlock his door with their keys and enter). He called himself and the other residents "inmates", as if they were incarcerated. "Believe me, John", he frequently said, "Half the people here, they'd like to just not wake up tomorrow morning -- but they won't let you die because they keep barging in".

The remedies, which Gawande wholly supports, is to return autonomy, decision-making, and the elements of normal everyday to the elderly. Gawande reports on several assisted living centers that are experimenting, both architecturally and programmatically to make this possible. My favorite was the hilarious experiment in New Berlin, New York, bringing pets into a nursing home to live with the residents -- dozens of parakeets, dogs, and cats. The delightful chaos and crises alone of feeding and caring for these creatures transformed the place. The point of all the experiments he details is that they brought a normal life back to the residents -- life was worthwhile.

Gawande is a bit light in telling us the long-term effects of the experiments. Do they actually work financially, administratively? I agree they sound like better alternatives (I'd much rather be in a place with parakeets, dogs and cats), but I didn't learn enough about whether actual large-scale changes have taken effect because of these experiments. Nor does Gawande really delve into situations where elderly patients have declining mental abilities. The examples he gives of elderly and cancer patients near the end of their lives are of people who still have all their moral and mental capabilities. Yet, when you enter a nursing home, you immediately see many patients who don't have the capacity to decide for themselves, or who are very confused. The Alzheimer's ward is a very difficult place.

The second focus of the book is on the central dilemma facing a dying man or woman: should we employ medicine to fight the onset of our deaths in the hope of a cure or of extending our lives? He shows how that often relegates us to even more intense suffering from medical side effects, impaired mobility and communication, and often brings no cure or extension of life. Or should we choose to accept death as imminent, forego medical interventions, and concentrate on living the last period of life as pain free as possible, so that we can enjoy this period as much as possible and communicate as much as possible with loved ones?

Another way of putting is -- do you want to let your disease take its course and live a worthwhile, bearable life in your few final days, or do you want to attempt to lengthen those final days by continuing the struggle against your affliction, which is likely going to kill you no matter what you do?

Gawande examines a number of patients who faced heart-wrenching choices because of their diseases (including the touching story of his own father, who was afflicted with terminal spinal cancer in his last years). He carefully records his own fumbling attempts as a surgeon to help patients with their difficult choices, and demonstrates how ill-prepared doctors are to talk about these issues with their patients. He repeatedly argues for helping the patient to spend the remaining time in his or her life in control of their mental faculties, in control of moral decision-making, to get whatever enjoyment is left to them without struggling against the inevitable. Some would call this "giving in" or "surrendering". He acknowledges that each case is individual, that seemingly miraculous cures do occur, but the arc of his argument tends towards palliative care, to reduce the suffering of the patient and allow as much dignity to the patient while their disease works its course.

Here is a quote from page 141, which I think is at the heart of the book. "The battle of being mortal is the battle to maintain the integrity of one's life -- to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be. Sickness and old age make the struggle hard enough. The professionals and institutions we turn to should not make it worse."

Gawande does not bring up children who are faced with the ends of their short lives. I suppose that's a different book. Children, or very young people, who are near death because of disease or accident, would have raised another set of moral issues. Can the children make their own decisions? Who makes the decisions for them?

Murderously insane and likeable at the same time: Sweeney Todd, at the Kavinoky Theater

Sweeney Todd, the Demon Barber of Fleet Street. Music by Stephen Sondheim, book by Hugh Wheeler. At the Kavinoky Theater, directed by John Fredo.

The complicated Victorian-era story is about a man who was wrongly accused of a crime and sentenced to prison in Australia for fifteen years. On his return to London, he is told his beautiful daughter has become the ward (actually, concubine) of the evil judge who sentenced him, and that his wife has since poisoned herself. To wreak his revenge, he takes the name of Sweeney Todd, sets himself up as a barber above a meat pie shop and the friendly woman who helps him, and murders a slew of customers, ultimately murdering the judge himself.

I had never seen this musical before. I love Sondheim. This is of course a macabre, grotesque story, full of sometimes humorous songs that belie and are dissonant to the murderous events. That's Sondheim. If it's possible to enjoy a play where you like and feel moved by people who are insanely murderous, then this is that play. Todd is insane. Mrs. Lovett, who makes meat pies out of the corpses of Todd's victims, is insane. They cold-bloodedly murder people who have done them no harm. Yet, we like them, their songs are about love, affection, overcoming hardships. How can we not like them and feel moved by their complicated stories?

There is that central falsehood in this play. The lyricist can give Todd and Mrs. Lovett these songs. The playwright can put reasonable words in their mouths, and give them actions that show them to be compassionate, caring people. Yet they are monsters who cut the throats of innocents as well as evil judges. In what reality can such a story take place?

The cast and the entire production were great. Matt Witten's Todd was controlled and restrained. Todd is seething with rage, and yet we see a quiet, almost contemplative Todd on the stage (up until the instant he slits the throats of his victims). Witten's restraint, and the music, heightened the tension leading up to the two attempts on the judge's life -- almost unbearable, Sweeney Todd wielding the razor, we know what he's about to do, and he's singing. Anthony Lazzaro was exceptional as the young innocent sailor Anthony Hope (great name).