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The Sunday Interview: Managing mortality

Author-surgeon Atul Gawande talks about his book on aging and dying, his research interests, and writing for The New Yorker.

October 11, 2014 05:42 pm | Updated May 23, 2016 05:28 pm IST

Atul Gawande. Photo: Tim Llewellyn

Atul Gawande. Photo: Tim Llewellyn

In today’s world, medical advances have given us an arsenal of tools to combat death, but this often comes at the cost of the quality of life. In his latest book, Being Mortal , surgeon and writer Atul Gawande explores the concepts of aging and dying in the U.S. Using personal accounts of patients and family members, Dr. Gawande seeks answers to the questions we are all eventually forced to confront: In the end, what matters most? How do we want to die? Excerpts from an interview:

What got you interested in an in-depth investigation on aging and dying?

I have been a surgeon taking care of the seriously ill for more than a decade now. I also saw my parents reach their seventies with a series of mounting difficulties in their lives. And it became apparent that the way we, in medicine and society, commonly manage mortality is poor and inhumane. But I didn’t know why or how we might do better. This was my way of trying to find out.

WhileBeing Mortalis primarily set in the U.S., it is also relevant to many Indians who have made the transition from being in joint to nuclear families. What is the one piece of advice that you would give to the elderly and their children?

Yes, I trace the course of my grandfather, who lived to 110 years, surrounded by a large family and living the kind of old age we would all want to have. But it was possible only because young people — especially young women — were more or less enslaved by the needs of the old. Economic progress has come from giving young people freedom — to live where they want, work where they want, marry whom they want. But there is no plan for what happens to the old left behind.

Two interesting things that I’ve learned from the pattern of what happens around the world: One, your parents don’t want to live with you if they don’t have to. They like their independence, and they don’t want to move into your home and follow your rules. You don’t want to live your adult life following their rules either. So the solution that people often come to is living at ‘an intimate distance’ — near one another, but apart.

Two, this works until your parents can’t take care of themselves anymore. We don’t have any tradition of discussing that possibility in advance. But it’s hugely important to have that conversation — to talk with one another about what fears and worries parents have if their health worsens; what goals they have; what tradeoffs they are willing or not willing to make in their lives. These conversations are incredibly important — and they can transform your relationships.

In the book, you discuss assisted dying in the Netherlands, where its usage has seen an increase. What are your views on this concept, especially in the context of old age or incurable illness?

I fear that it is the wrong goal. I fully believe that people experiencing unbearable suffering should be given treatment for relief from pain and distress even if it risks their lives. But the goal is not that people have a good death. Our goal needs to be assuring people to have as good a life as possible all the way to the very end. Too often we jump to offering the seriously ill assistance with dying when we’ve never offered what is ultimately most important — assistance with living. This book is about how much more is possible when we take this concept seriously.

You have narrated personal accounts of close family members, such as your grandfather and father. How did you decide what — and how much — you wanted to share. How did the rest of your family feel about it?

I couldn’t have told the story without the help my family. My mother and sister in particular were extraordinary. In choosing to include the story of my father’s decline and death — and I held nothing back — I know I dredged up moments they’d rather not relive or necessarily told the way I did. Nonetheless, they helped me at every turn, answering my difficult questions, probing their memories, and tracking down everything from memorabilia to medical records. My family in Maharashtra helped too, sending me old letters and photographs, gathering memories, and helping me check numerous details.

You read philosophy and politics at Oxford as a Rhodes Scholar, and then worked in U.S. politics for a while too. What prompted the shift to medicine?

Well, as the son of two Indian physicians, you can imagine it was always assumed I’d become a doctor; so going to Oxford to study philosophy and working in U.S. politics was a kind of tame rebellion. But I felt at home in hospitals and with the sick because of my upbringing. And medicine’s values — to relieve suffering and help people achieve their potential — were the same ones I was pursuing in my work in politics and in my studies. All along I had also been admitted to medical school but kept deferring. Eventually, I had to admit it was the place I belonged.

As a Staff Writer forThe New Yorker, how do you find new topics to write aboutfor your essays?

Oh gosh, that isn’t hard. I like writing about things that confuse me — what do we do about the terrible way we care for the dying or the very old? Why are healthcare costs so high? Why do we itch? I keep a running list of things I’d like to write about on my computer. It’s past 300 entries. I’ll never get to them all.

Could you tell us something about the research you're conducting in India through your association with the research centre, Ariadne Labs?

I helped found a research centre at Harvard and my hospital that grew out of the work I wrote about in my last book, The Checklist Manifesto. We’d found that simple approaches for handling complexity — such as following a checklist — could produce massive improvements in care. For instance, a checklist for surgical teams that we designed with the World Health Organisation reduced deaths by 47 per cent, including in India. We’re now testing deployment of a similar checklist for safe childbirth. We’d tested in a pilot study in Karnataka where teams using the checklist adhered to key lifesaving practices (such as washing hands, warming a newborn properly, or giving appropriate medication to stop bleeding) far more consistently. Now, we’re testing this approach at large scale in Uttar Pradesh in many thousands of deliveries with the State and national government, WHO, the Gates Foundation, and local partners in U.P. like Population Services International and the Community Empowerment Lab.

You take a keen interest in public policy issues in the U.S, especially in the field of healthcare. What do you feel should be our priority in India in tackling the many healthcare challenges we face?

I don’t want to presume to tell India what to do. But what I see in my work and in my family in India is that there is real suffering because people cannot trust that, when they are sick or injured, they can count on finding people who care; whether it is the private sector or the public sector. The levels of safety, quality, and caring are not adequate to their needs. The place that most countries start is with transparency — more journalists need to write about these; doctors, NGOs, and government need to track and measure these problems; and leaders need to constantly experiment to make improvements. In India, this is happening in childbirth and a few other areas. But the poor quality of care that I see people experience in the private sector and in the public sector is still not on the agenda.

What’s next on the cards?

Our research work seeking scalable solutions for better care at the most critical moments in people’s lives continues to grow and expand. And I am already at work on another essay for The New Yorker , which has been my home for writing for almost two decades now. What is the essay about? Ah, that I can’t tell you.

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