”The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. If you don’t, mortality is only a horror.”
I wonder if Gawande doesn't have that a little bit wrong. It is life that is meaningless and a misery without a larger connection, not death. Death may be a balm to those with no one to tether them, to tend to them.
My great aunt lived to be 102 years old. She would often say, looking at the younger generations, “It’s wonderful to get old.” Gawande touches on this in his memoir chronicling the death of his father and in his discussion of dying well. Older folks have more moments they classify as happy than do younger folks. Oldsters generally experience less anxiety, too, perhaps from having “seen it all before,” but perhaps also because they know bad times do pass. Usually.
I still think my great aunt was being just a little facetious, since the rest of Gawande’s book tells us pretty explicitly that old age is not for wimps. In fact, as Elizabeth Gilbert suggested in her novel The Signature of All Things, we do better when we turn towards “the great changes that life brings” rather than turn our wills away. Gawande tells us how it is possible in some cases to choose less treatment rather than more when faced with life-threatening illness and experience a better quality of life in our final days.
This is pretty grim stuff but Gawande is graceful, as graceful as he can be when the choices are so limited and so frankly horrible. When a loved one (or we ourselves) must make choices, it is wise, he counsels, to ask ourselves a few questions: What do we fear most? What do we want most to be able to do? What can/can’t we live without? What will we sacrifice so that we can accomplish what it is we want? Our choices may change as circumstances change, so one has to revisit occasionally, to make sure we (and our family and our doctors) are proceeding along the path we have chosen for ourselves.
It is almost, but perhaps not quite, enough to make one wish for a sudden, early death. We all must go through it, so we’re not alone. It’s just that medical knowledge, technology, and skill can do only so much, and after that we still have to face the inevitable. Gawande gives lots of examples of patients and of people he has known who have these choices thrust upon them. On balance, he concludes, those who accept, rather than thoughtlessly fight, a terminal prognosis have a better death.
This book is worth reading, maybe more so before you need it. Filling out the hospital’s required “health care directive” is actually difficult unless you have someone like this to explain what it actually means. No intervention may mean weeks instead of months; it may also mean calm instead of recovering from radical surgery. It may just be unbearably depressing. I get that.
One interesting study Gawande talks about is one in which people who know their time horizons are short, or who experience life-threatening conditions (e.g., living in a war zone, 9/11, surviving a tsunami) change their view of what they want out of life, their "hierarchy of needs" as defined by Maslow. People with unlimited horizons put a high premium on growth and meeting people who are interesting and influential. Those with foreshortened horizons look to their closest friends and family for sustenance and comfort. War zones may not grant you friends or family, but certainly intense, highly-charged, and memorable relationships result from them. Little is expected, much is granted. And I guess that is key. There is more generosity to go around when one is in the final days and it may be best not to occlude that blessing with a confusion of treatments that do not mean a better life.
Gawande addresses some of the most difficult questions we have to decide in a lifetime. It is not easy to read. But it helps, I think, to know what choices we can make when the time comes for someone we love or for ourselves.
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