American attitudes regarding aging, death, and dying are evolving. More Americans are choosing to receive care and die at home, and the growing availability of home care options has made this increasingly possible.
Multiple factors appear to be driving this trend, not the least of which is the high cost of end-of-life care. According to Atul Gawande, M.D. in “Being Mortal,” published in 2014, now available in paperback, “An important concern in US health care policy involves the high cost of health care and the adequacy of care quality provided to seriously ill “high-need, high-cost” patients. In the United States, 5% of persons account for 60% of health care expenditures. Death is usually preceded by prolonged illness, and about 80% of individuals are considered high-need, high-cost patients prior to death.” Data suggests that 75% of Medicare costs are incurred in the last six weeks of a patient’s life.
But economic concerns are only a part of this problem. Adequacy of health care quality in the last weeks of life has grown as an issue as well. Gawande states, “Research has found poor palliation of symptoms, burdensome health care transitions during the last days of life, reports of unmet patient needs, concerns with the quality of care, and declines in the ratings for patient care quality.”
Gawande details the issues people face as they age, experience deterioration of function, and approach death. In many eastern cultures the aging individual is regarded as a person of great wisdom and a source of family cohesion. It is considered the responsibility of the extended family to provide care for the aged and the dying. This is seen as a privilege, not a burden. In the United States care of the elderly has become largely a matter of institutionalization.
In “Being Mortal” Gawande describes the development of facilities that permit the elderly and infirm to live with the greatest possible degree of independence, yet he decries the monetization, in many cases, of such facilities.
Gawande’s motivation for writing this book was not merely professional. He describes the transition of his father, a robust, tennis-playing surgeon, from active life through disability and dependency to death from a rare central nervous system tumor. During the years of his father’s illness Gawande became aware of the burdens imposed on the aged, infirm and dying. This book is his response to these issues and his celebration of the society’s attempts to answer them.
In the five years since its hardcover publication “Being Mortal” has become a resource not only for health care practitioners, but also for those who are facing these issues, whether personally or as caregivers for individuals experiencing the declines of the latter years of life. Thoughtful readers will find this well-written book helpful in guiding their thinking about their mortality as well as the mortality of those they love.