“As recently as 1945, most deaths occurred in the home. By the 1980s, just 17 percent did. … The experience of advanced aging and death has shifted to hospitals and nursing homes.”

Given that Maine has the oldest population in the nation, all of us should read Dr. Atul Gawande’s new book, “Being Mortal, Medicare and What Matters in the End.” As a Mainer now enrolled in Medicare, I found the book to be especially informative and helpful.

Gawande was named one of the world’s top 100 thinkers by Time magazine. He is a surgeon at Brigham and Women’s Hospital in Boston, a professor at Harvard Medical School and director of Adriadne Labs, a center for health systems innovation, as well as an author of three previous award-winning books.

This book is very sobering. “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions — nursing homes and intensive care units — where regimented, anonymous routines cut us off from all the things that matter to us in life,” Gawande writes. He says he “wrote this book in the hope of understanding what has happened. Mortality can be a treacherous subject.”

But he doesn’t make the subject treacherous in this book. In fact, after taking us through a comprehensive examination of the problem, he offers solutions. We’ll get to that later. Let’s start with the problem.

We have transitioned from a time when most senior citizens lived with their kids, to a time when most live alone. Gawande calls this “enormous progress. Choices for the elderly have proliferated. (But) there remains one problem with this way of living. Our reverence for independence takes no account of the reality of what happens in life: Sooner or later, independence will become impossible.”


The chapter titled “Things Fall Apart” starts with our teeth and ends with memory and judgment. Well, I guess it’s good to enter old age with full knowledge of what’s ahead. None of us would return to the Roman Empire when average life expectancy was 28 years.

The book presents lots of successful, innovative programs to resolve the problems of old age. For example, researchers at the University of Minnesota studied men and women older than 70 who were living independently, but were at high risk of becoming disabled. Half of them were assigned to a team of geriatric nurses and doctors, who were dedicated to managing old age. Those patients were a quarter less likely to become disabled, half as likely to develop depression and 40 percent less likely to require home health services. Gawande noted, “These were stunning results.” And of course, lots of money was saved.

The geriatric teams “simplified medications, controlled arthritis, made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe.”

But here’s the problem: Medicare doesn’t cover the cost of geriatric care. Because of this, “scores of medical centers across the country have shrunk or closed their geriatric units,” reports Gawande.

I learned that “use of hospice care has been growing steadily — to the point that, by 2010, 45 percent of Americans died in hospice. More than half of them received hospice care at home.” My father died after six months in the Togus Hospice Unit, and those six months were an amazing, uplifting experience for all of us.

Gawande notes that hospice care “represents a struggle — not only against suffering but also against the seemingly unstoppable momentum of medical treatment.”


“People with serious illness have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars.”

He asks a good question: “How can we build a health care system that will actually help people achieve what’s most important to them at the end of their lives?” Turns out the answer is simple: You ask them.

“People who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish,” reports Gawande. “If end-of-life discussions were an experimental drug, the FDA would approve it.” he says. Research has proven his point that “you live longer only when you stop trying to live longer.”

The final chapter, titled “Courage,” is — well — encouraging. “One has to decide whether one’s fears or one’s hopes are what should matter most,” writes Gawande.

The book includes some very sad stories, but I focused on the amazing inspirational stories. There are plenty of those. And I promise you — after you have read this book — you will be able to write your own end-of-life story so that it represents your wishes.

George Smith is a writer and TV talk show host. He can be reached at 34 Blake Hill Road, Mount Vernon 04352, or [email protected]. Read more of Smith’s writings at www.georgesmithmaine.com.

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