Being Mortal: Medicine and What Matters in the End (32 page)

As the oldest male in the family, I was called upon to assist with the rituals required for my father to achieve
moksha
—liberation from the endless earthly cycle of death and rebirth to ascend to nirvana. The pandit twisted a ring of twine onto the fourth finger of my right hand. He had me hold the palm-size brass urn that contained my father’s ashes and sprinkle into it herbal medicines, flowers, and morsels of food: a betel nut, rice, currants, rock crystal sugar, turmeric. He then had the other members of the family do the same. We burned incense and wafted the smoke over the ashes. The pandit reached over the bow with a small cup and had me drink three tiny spoons of Ganga water. Then he told me to throw the urn’s dusty contents over my right shoulder into the river, followed by the urn itself and its cap. “Don’t look,” he admonished me in English, and I didn’t.

It’s hard to raise a good Hindu in small-town Ohio, no matter how much my parents tried. I was not much of a believer in the idea of gods controlling people’s fates and did not suppose that anything we were doing was going to offer my father a special place in any afterworld. The Ganges might have been sacred to one of the world’s largest religions, but to me, the doctor, it was more notable as one of the world’s most polluted rivers, thanks in part to all the incompletely cremated bodies that had been thrown into it. Knowing that I’d have to take those little sips of river water, I had looked up the bacterial counts on a Web site beforehand and premedicated myself with the appropriate antibiotics. (Even so, I developed a
Giardia
infection, having forgotten to consider the possibility of parasites.)

Yet I was still intensely moved and grateful to have gotten to do my part. For one, my father had wanted it, and my mother and sister did, too. Moreover, although I didn’t feel my dad was anywhere in that cup and a half of gray, powdery ash, I felt that we’d connected him to something far bigger than ourselves, in this place where people had been performing these rituals for so long.

When I was a child, the lessons my father taught me had been about perseverance: never to accept limitations that stood in my way. As an adult watching him in his final years, I also saw how to come to terms with limits that couldn’t simply be wished away. When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that there are times when the cost of pushing exceeds its value. Helping my father through the struggle to define that moment was simultaneously among the most painful and most privileged experiences of my life.

Part of the way my father handled the limits he faced was by looking at them without illusion. Though his circumstances sometimes got him down, he never pretended they were better than they were. He always understood that life is short and one’s place in the world is small. But he also saw himself as a link in a chain of history. Floating on that swollen river, I could not help sensing the hands of the many generations connected across time. In bringing us there, my father had helped us see that he was part of a story going back thousands of years—and so were we.

We were lucky to get to hear him tell us his wishes and say his good-byes. In having a chance to do so, he let us know he was at peace. That let us be at peace, too.

After spreading my father’s ashes, we floated silently for a while, letting the current take us. As the sun burned away the mist, it began warming our bones. Then we gave a signal to the boatman, and he picked up his oars. We headed back toward the shore.

Notes on Sources

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INTRODUCTION

Tolstoy’s classic novella: Leo Tolstoy,
The Death of Ivan Ilyich
, 1886 (Signet Classic, 1994).

I began writing: A. Gawande,
Complications
(Metropolitan Books, 2002).

As recently as 1945: National Office of Vital Statistics,
Vital Statistics of the United States, 1945
(Government Printing Office, 1947), p. 104,
http://www.cdc.gov/nchs/data/vsus/vsus_1945_1.pdf
.

In the 1980s: J. Flory et al., “Place of Death: U.S. Trends since 1980,”
Health Affairs
23 (2004): 194–200,
http://content.healthaffairs.org/content/23/3/194.full.html
.

Across not just the United States: A. Kellehear,
A Social History of Dying
(Cambridge University Press, 2007).

The late surgeon Sherwin Nuland: S. Nuland,
How We Die: Reflections on Life’s Final Chapter
(Knopf, 1993).

1: THE INDEPENDENT SELF

Even when the nuclear family: P. Thane, ed.,
A History of Old Age
(John Paul Getty Museum Press, 2005).

one child usually remained: D. H. Fischer,
Growing Old in America: The Bland-Lee Lectures Delivered at Clark University
(Oxford University Press, 1978). Also C. Haber and B. Gratton,
Old Age and the Search for Security: An American Social History
(Indiana University Press, 1994).

the poet Emily Dickinson: C. A. Kirk,
Emily Dickinson: A Biography
(Greenwood Press, 2004).

surviving into old age was uncommon: R. Posner,
Aging and Old Age
(University of Chicago Press, 1995), see ch. 9.

They tended to maintain their status … Whereas today people often understate: Fischer,
Growing Old in America
.

In America, in 1790: A. Achenbaum,
Old Age in the New Land
(Johns Hopkins University Press, 1979).

today, they are 14 percent: United States Census Bureau,
http://quickfacts.census.gov/qfd/states/00000.html
.

In Germany, Italy, and Japan: World Bank,
http://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS
.

100 million elderly: “China’s Demographic Time Bomb,”
Time
, Aug. 31, 2011,
http://www.time.com/time/world/article/0,8599,2091308,00.html
.

As for the exclusive hold: Posner, ch. 9.

increased longevity has brought: Haber and Gratton, pp. 24–25, 39.

Historians find that the elderly … The radical concept of “retirement”: Haber and Gratton.

Life expectancy: E. Arias, “United States Life Tables,”
National Vital Statistics Reports
62 (2014): 51.

Family sizes fell: L. E. Jones and M. Tertilt, “An Economic History of Fertility in the U.S., 1826–1960,”
NBER Working Paper Series
, Working Paper 12796, 2006,
http://www.nber.org/papers/w12796
.

The average age at which: Fischer, appendix, table 6.

“intimacy at a distance”: L. Rosenmayr and E. Kockeis, “Propositions for a Sociological Theory of Aging and the Family,”
International Social Science Journal
15 (1963): 410–24.

Whereas in early-twentieth-century America: Haber and Gratton, p. 44.

The pattern is a worldwide one: E. Klinenberg,
Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone
(Penguin, 2012).

Just 10 percent: European Commission,
i2010: Independent Living for the Ageing Society
,
http://ec.europa.eu/information_society/activities/ict_psp/documents/independent_living.pdf
.

Del Webb: J. A. Trolander,
From Sun Cities to the Villages
(University Press of Florida, 2011).

2: THINGS FALL APART

trajectory of our lives: J. R. Lunney et al., “Patterns of Functional Decline at the End of Life,”
Journal of the American Medical Association
289 (2003): 2387–92. The graphs in this chapter are adapted from the article.

By the middle of the twentieth century: National Center for Health Statistics,
Health, United States, 2012: With Special Feature on Emergency Care
(Washington, DC: U.S. Government Printing Office, 2013).

People with incurable cancers … The curve of life becomes a long slow fade: J. R. Lunney, J. Lynn, and C. Hogan, “Profiles of Older Medicare Decedents,”
Journal of the American Geriatrics Society
50 (2002): 1109. See also Lunney et al., “Patterns of Functional Decline.”

Consider the teeth: G. Gibson and L. C. Niessen, “Aging and the Oral Cavity,” in
Geriatric Medicine: An Evidence-Based Approach
, ed. C. K. Cassel (Springer, 2003), pp. 901–19. See also I. Barnes and A. Walls, “Aging of the Mouth and Teeth,”
Gerodontology
(John Wright, 1994).

the muscles of the jaw lose: J. R. Drummond, J. P. Newton, and R. Yemm,
Color Atlas and Text of Dental Care of the Elderly
(Mosby-Wolfe, 1995), pp. 49–50.

By the age of sixty: J. J. Warren et al., “Tooth Loss in the Very Old: 13-15-Year Incidence among Elderly Iowans,”
Community Dentistry and Oral Epidemiology
30 (2002): 29–37.

Under a microscope: A. Hak et al., “Progression of Aortic Calcification Is Associated with Metacarpal Bone Loss during Menopause: A Population-Based Longitudinal Study,”
Arteriosclerosis, Thrombosis, and Vascular Biology
20 (2000): 1926–31.

Research has found that loss of bone density: H. Yoon et al., “Calcium Begets Calcium: Progression of Coronary Artery Calcification in Asymptomatic Subjects,”
Radiology
224 (2002): 236–41; Hak et al., “Progression of Aortic Calcification.”

more than half of us: N. K. Wenger, “Cardiovascular Disease,” in
Geriatric Medicine
,
ed. Cassel (Springer, 2003); B. Lernfeit et al., “Aging and Left Ventricular Function in Elderly Healthy People,”
American Journal of Cardiology
68 (1991): 547–49.

muscle elsewhere thins: J. D. Walston, “Sarcopenia in Older Adults,”
Current Opinion in Rheumatology
24 (2012): 623–27; E. J. Metter et al., “Age-Associated Loss of Power and Strength in the Upper Extremities in Women and Men,”
Journal of Gerontology: Biological Sciences
52A (1997): B270.

You can see all these processes: E. Carmeli, “The Aging Hand,”
Journal of Gerontology: Medical Sciences
58A (2003): 146–52.

This is normal: R. Arking,
The Biology of Aging: Observations and Principles
, 3rd ed. (Oxford University Press, 2006); A. S. Dekaban, “Changes in Brain Weights During the Span of Human Life: Relation of Brain Weights to Body Heights and Body Weights,”
Annals of Neurology
4 (1978): 355; R. Peters, “Ageing and the Brain,”
Postgraduate Medical Journal
82 (2006): 84–85; G. I. M. Craik and E. Bialystok, “Cognition Through the Lifespan: Mechanisms of Change,”
Trends in Cognitive Sciences
10 (2006): 132; R. S. N. Liu et al., “A Longitudinal Study of Brain Morphometrics Using Quantitative Magentic Resonance Imaging and Difference Image Analysis,”
NeuroImage
20 (2003): 26; T. A. Salthouse, “Aging and Measures of Processing Speed,”
Biological Psychology
54 (2000): 37; D. A. Evans et al., “Prevalence of Alzheimer’s Disease in a Community Population of Older Persons,”
JAMA
262 (1989): 2251.

Why we age: R. E. Ricklefs, “Evolutionary Theories of Aging: Confirmation of a Fundamental Prediction, with Implications for the Genetic Basis and Evolution of Life Span,”
American Naturalist
152 (1998): 24–44; R. M. Zammuto, “Life Histories of Birds: Clutch Size, Longevity, and Body Mass among North American Game Birds,”
Canadian Journal of Zoology
64 (1986): 2739–49.

The idea that living things shut down: C. Mobbs, “Molecular and Biologic Factors in Aging,” in
Geriatric Medicine
, ed. Cassel; L. A. Gavrilov and N. S. Gavrilova, “Evolutionary Theories of Aging and Longevity,”
Scientific World Journal
2 (2002): 346.

average life span of human beings: S. J. Olshansky, “The Demography of Aging,” in
Geriatric Medicine
, ed. Cassel; Kellehear,
A Social History
.

As Montaigne wrote: Michel de Montaigne.
The Essays
, sel. and ed. Adolphe Cohn (G. P. Putnam’s Sons, 1907), p. 278.

inheritance has surprisingly little influence: G. Kolata, “Live Long? Die Young? Answer Isn’t Just in Genes,”
New York Times
, Aug. 31, 2006; K. Christensen and A. M. Herskind, “Genetic Factors Associated with Individual Life Duration: Heritability,” in J. M. Robine et al., eds.,
Human Longevity, Individual Life Duration, and the Growth of the Oldest-Old Population
(Springer, 2007).

If our genes explain less: Gavrilov and Gavrilova, “Evolutionary Theories of Aging and Longevity.”

Hair grows gray: A. K. Freeman and M. Gordon, “Dermatologic Diseases and Problems,” in
Geriatric Medicine
, ed. Cassel, 869.

Inside skin cells: A. Terman and U. T. Brunk, “Lipofuscin,”
International Journal of Biochemistry and Cell Biology
36 (2004): 1400–4; Freeman and Gordon, “Dermatologic Diseases and Problems.”

The eyes go: R. A. Weale, “Age and the Transmittance of the Human Crystalline Lens,”
Journal of Physiology
395 (1988): 577–87.

the “rectangularization” of survival: Olshansky, “The Demography of Aging.” See also US Census Bureau data for 1950,
http://www.census.gov/ipc/www/idbpyr.html
. Additional data from Population Pyramid online,
http://populationpyramid.net/
.

We cling to the notion of retirement: M. E. Pollack, “Intelligent Technology for an Aging Population: The Use of AI to Assist Elders with Cognitive Impairment,”
AI Magazine
(Summer 2005): 9–25. See also Federal Deposit Insurance Corporation,
Economic Conditions and Emerging Risks in Banking: A Report to the FDIC Board of Directors
, May 9, 2006,
http://www.fdic.gov/deposit/insurance/risk/2006_02/Economic_2006_02.html
.