Formerly IGSW News | VOLUME 22 | SUMMMER 2015

From the Director

'Being Mortal: Medicine and What Matters in the End'

For Appropriate, Effective Care, Acknowledge Death and Dying

By Scott Miyake Geron

ScottAmericans don't like to acknowledge aging and death, much less read about them, so it's heartening that Atul Gawande's Being Mortal: Medicine and What Matters in the End has received such a wide, appreciative audience in the short time since it was published last fall. I read it with an eye toward implications for people working in long-term supports and services.

Gawande, a surgeon and a writer on medical matters for The New Yorker, presents this book as a conversation we all must have. In it, he criticizes members of his own profession for the "medicalization of mortality," saying doctors focus too much on safety and survival for their end-of-life patients. Instead, he says, they should be working to provide a less harrowing, more personally meaningful time of life for people facing serious illness and the possible approach of death. Doctors should ask, How do you want to live at this time? What matters to you?

As Gawande calls for change in the philosophy of how we care for those facing their own mortality, he also observes that some medical students now receive training in a more thoughtful philosophy of end-of-life care. For contrast, he offers his younger self and fellow interns confronted with a patient with incurable cancer who opted for heroic treatment, with little chance of success: "We could never bring ourselves to talk to him about the truth of his condition or the ultimate limits of our capabilities, let alone what might matter most to him as he nears the end of his life."

Rather than offering specific remedies, Gawande presents a range of vignettes and profiles and poses questions. He obviously places great importance on providers of supports and care, who, as we know, are most engaged with how people live while dying. He acknowledges the "scores of frontline staff in homes for the aged, palliative care specialists, hospice workers, nursing home reformers, pioneers, and contrarians who showed me places and ideas I'd never have encountered." For example, he singles out nursing home reformer Bill Thomas and Keren Brown Wilson, an assisted living pioneer.

Certainly, hospice workers and front-line caregivers have long known what Gawande is now discovering. But it's medicine that has the most pronounced influence on the whole scheme of how we live, age, and die. One of the problems I have seen that I would have liked Gawande to address more is the unintended consequences of the Medicare hospice benefit, which tends to restrict those services until the very end of life and results in too many deaths occurring in hospitals. We need to liberalize the hospice benefit. We also must address the urgent need to train more front-line workers in provision of the palliative services that are a crucial part of hospice.

It will also be very interesting to see how the new Medicare proposal to cover "end of life," or advance care-planning, discussions between patients and their physicians—and other providers—plays out.

Scott Miyake Geron, Ph.D., is director of CADER and associate professor at Boston University School of Social Work.

Boston University photo of Scott Miyake Geron

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Copyright © 2015 Trustees of Boston University. All rights reserved. This article may not be duplicated or distributed in any form without written permission from the publisher: Center for Aging & Disability Education & Research, Boston University School of Social Work, 264 Bay State Road, Boston, MA 02215, U.S.A.; e-mail: