Being Mortal: Medicine and What Matters In The End by Atul Gawande

This book made me think a lot about the aging of my parents just like my friend said that it made her think about.

• To me in particular it made me think about or rethink about assisted living homes and if I will put my parents in one.
• I used to always joke to my mother that I would put them in a nursing home because I’m don’t think of myself as a particularly caring person. My brother will be a nurse, but I’m not gonna burden him with that.
• I agree heavily with the multigenerational living model. I don’t know if I will have kids, so especially if I don’t have children then it seems like I should be having my parents in my house both to make me and them feel less alone.

This book also made me think about the aging of my grandparents.

• My grandfather died in hospice widowing my grandmother and she’s been largely independent, but has been in assisted living facility for a while. The people in assisted living facility are generally happy, but when she’s been sick/injured and in the rehab center I’ve definitely seen some incredibly heartbreaking scenes.
• My father‘s parents are aging as well and they’re still very largely independent with social circles that are outside of nursing homes. The wear and tear of their bodies is getting to them and some of their friends are moving to nursing homes.
  • They love their house and a lot of children and grandchildren have spent a lot of their lives there and so there’s also the idea of what the house and independence represents to them and how it can be a family gathering place.

This book and the complex system failure model of the human body kind of scares me.

• I agree with the author, and that I don’t think that lifespan is genetically programmed, but that almost makes it scarier, because lifespan is largely unpredictable.
• There are ways that you can optimize, but it seems like it’s almost fear based and you don’t really know if what you’re gonna do is working. you’re doing something for unknown payoff in the future, which is totally against, the human motivation system

The economics of geriatrics and Medicare billing practices disincentivize investment in aging solutions.

• The author makes a great point that if it was a medical device or some kind of silver bullet solution, everyone would be clamoring to fund it, but instead just visits to a geriatric specialist were improving outcomes vastly, and then they were just shutter the entire program it just boggles the mind
• There some truth to the idea that we don’t want to fund geriatrics just because we want to avert our eyes from the aging process. I feel like that’s part of it but on a broader, societal level there are much more concrete reasons why geriatrics is not a sexy field like salary.
• More investment in aging solutions would actually decrease medical spending on older people. Increasing palliative care availability and hospice eligibility leads to reduced medical costs as well as patient suffering. Increasing medical spending begets further medical spending because surgery, medication, and radiation recovery and side effects cause a need for more spending and intensive care.

I love the general centering of quality of life and discussions around that.

• When I read When Breath Becomes Air, he spoke about his experience as a neurosurgeon where you have to really understand the effects of what you are doing to these people, because what is life if you’re just living on a defibrillator, and in a coma or something like that.
• I wonder how much of aging related mental symptoms are generational. People assign so much value and their worth for what they can do for people and so cognitive slippage is to be abhorred. People don’t want to be or admit that they are vulnerable.
  • For things like dementia I’m sure there is a physical and/or neurological basis for confusion and agitation, but how much of it is because they cannot accept the fact that they could be wrong?
• With a focus on quality of life comes the idea of having a purpose. With physical decline and cognitive impairment abound there needs to be a way to create assistive technologies or scaffold activities/organizations that allow older people to maintain a purpose so that they have structured to their day or something look forward to, to think about, to feel.

I think automation has a lot of potential for freeing up bandwidth within nursing home communities to allow humans to really focus on the more important social aspects of health and not be bogged down by having to change sheets and deliver food and all these things.

• This wasn’t been discussed by the author, and is more just a personal thought that I’ve had as a Software Engineer and a person who’s experienced having a grandmother in the nursing home community.
• Cost is a big reason for lack of access for a lot of people; this kind of full spectrum care is just expensive because of labor and equipment costs.

If the first medical goal was the extension of lifespan, then the next medical goal is quality of life across the extended lifespan.

• The solutions are just out of reach, if we just pour financial and intellectual resources into the problem then I truly believe that we can build a better society for an aging population.
• The author notes that living of fulfilling life when you’re old is just new, and it requires imagination and inventiveness because there’s not much prior work and also older people are just different, and they are less disabled, and so there are constraints of operation, but that should lead to innovation.

The concept around freedom and independence and the car for the elderly is such a solvable problem in my mind. It won’t be easy to implement, but I think that it can be done.

• The car accident statistics are not great with older people, but with things like public transportation, or just walkable communities in general would almost entirely eliminate this problem.
  • Walkable would also mean that they could ride a bike if able or at least a motorized scooter. Obviously not everyone will be able to walk, but there are plenty of ways to enable walking part way and then having other transportation options.
  • This would require significant investment in more accessible public transit.
• Transit systems can be confusing so I’m not sure how older adults with cognitive slippage would fare, but I’m sure that there are plenty of talented people that could think through this problem.

The author has a bit of an interesting view on death with dignity but I think that I’m fairly sympathetic to it

• He posits that the reason for the proliferation and popularity of assisted suicide in the Netherlands, is in part, because of the lack of palliative services, provided to people who may be suffering from terminal illnesses.
• He alleges that this sort of dependence on assisted suicide is in part of response to social attitudes and institutional inertia around redefining assisted living, which I do agree with.
• It is definitely hard to strike a balance of empowering people in taking control of their life while also controlling for the possibility that people are acting out of a temporary perspective.

I’m surprised I haven’t seen trendy millenial-type businesses that are trying to put a brand on the transition of aging and dying.

• I’m not sure what it would exactly look like, but I imagine something like an app or 24/7 hotline with a quirky name and colorful brand identity centered around centralizing aging services.
• I bet that at least some entrepreneurs have tried this but the fact that I haven’t heard of it certainly speaks to the success of the venture a little bit.