Surgeon and writer Atul Gawande explores ageing in a modern society in 'Being Mortal'

Author Atul Gawande explores the way society deals with death and ageing in in his book ‘Being Mortal’, highlighting that some doctors fail frail older people by using medicine to treat illnesses, at the expense of a person's quality of life.

Although he lives and works in the United States, his findings echo the types of problems faced in the UK, including the growing lack of doctors with expertise in geriatrics and a change in the family dynamic which has changed how they care for the older generations.

Mr Gawande is a surgeon, writer and public health researcher who recounts many stories of his experiences of ageing and society’s approaches to care and death.

He acknowledges the boom in medical progress which has increased life expectancy and greatly altered the population of which will see the United States have as many over 80 year olds as children under five in the next 30 years.

He explores how society has led people to feel embarrassed when their body fails them, where people compare themselves against marathon running 90 years olds and feel the need to apologise when they fail to live up to these expectations.

Writing from the point of view of a health professional, Mr Gawande wrote: “Our reluctance to honestly examine the experience of ageing and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology and strangers.”

Family care

One theme explored throughout the book is the change from older people living with family members to moving into care or using home care professionals as opposed to family members.

Instead of condemning this move, Mr Gawande celebrates it and shows the natural progression to this way of living which has suited all generations.

He recounts that when his grandfather reached old age people were cared for in multi-generational systems under one roof, and in some communities reaching old age was such an uncommon occurrence that people would lie about their age to receive the respect age brought from the community.

Mr Gawande said: “Demographers call the phenomenon ‘age heaping’ and have devised complex quantitative contortions to correct for all the lying in censuses.”

However once people started living longer, even the family ideal has seen threatening tensions created as older people retain wealth and property despite receiving care from younger family members.

Reflecting on the experiences of his own family in India, who cared for his ageing grandfather until he was 110 years old, Mr Gawande said: “You can imagine how my uncles felt as their father turned a hundred and they entered old age themselves, still waiting to inherit land and gain economic independence.

“I learned of bitter battles in village families between elders and adult children over land and money.”

This idealistic picture of living out old age with family members is shown in ‘Being Mortal’ to be, in reality, something neither young or old generations actually want.

The historical pattern shows that once people have the economic resources, they choose to leave home, and throughout history older people haven’t revealed signs of being as sorry to see children leave as is often assumed.

As more parents began to have longer lives after their children left, they started benefiting from renting or selling property instead of handing it down and the introduction of pension systems allowed them to retain economic control of their lives for longer.

Mr Gawande explained: “The elderly of the industrial era did not suffer economically and were not unhappy to be left on their own.

“So what they did was move on, just like their children. Given the opportunity, both parents and children saw separation as a form of freedom.”

Lou’s story

Throughout the book Mr Gawande tells stories of people who have experienced the way society reacts to older people and ageing.

The story of Lou and his daughter Shelley tells a familiar tale of people struggling to accept older age, and shows the common feelings of guilt and worry children experience when seeing their parents age. Lou had lived an independent life, having been the primary carer of his wife Ruth who had died of cancer at the age of 73 and continued to live independently for another 12 years.

When he reached the age of 88 he began having falls and after refusing to move into a care home Shelley helped him to move into her family home. They converted a bedroom and he gradually adapted to this form of living. The burden soon became too great for Shelley, who could not cope with his extra care needs while juggling other life pressures.

Mr Gawande reflected: “The burdens for today’s caregiver have actually increased from what they would have been a century ago. Shelley had become a round the clock concierge/ chauffer/ schedule manager/ medication and technology trouble shooter in addition to cook/ maid/ attendant, not to mention income earner.”

Moving into an assisted living property caused Lou to become depressed and Shelley noticed a lack of interest taken by the staff members. As a compromise Lou was able to spend half his time split between the assisted living home and Shelley’s home.

One of the founders of the idea of ‘assisted living’, Karen Brown Wilson, explained why often the reality of this way of living cannot live up to expectations.

“Most frustrating and important,” Ms Wilson told the book’s author: “is that assisted living isn’t really built for the sake of older people so much as for the sake of their children. They try to create what marketers call ‘the visuals’ the beautiful, hotel like entrance way, for instance that caught Shelley’s eye.

“Features speak more to what a middle aged person desires for a parent than to what the parent does.

“It’s a rare child who is able to think ‘is this place what mum would want or like or need?’”

By the age of 92 however Lou needed a higher level of care than a split life between assisted living and his daughter’s home could provide.

The book reflects on the way families have changed, with fewer children and less of an extended family to rely on in later life, leaving older people in a controlled and supervised existence, that is safe but sometimes lacking in things that are key to living.

It shows that doctors have approached old age with the view to treat and tackle individual illnesses as opposed to looking at the person and what they need as a whole.

However Lou’s story takes a turn for the better when he moves into a care home described by its maker Bill Thomas as built 'from the ground up.'

The home had taken the powers away from managers and given them to frontline staff. The home ensured each carer only has a small number of people to care for, creating a companion for people like Lou as opposed to a clinician who dealt with only their health and keeping them safe.

Lou called the place home, and remained there for the rest of his life.

Mr Gawande recounted how Lou had said: “I don’t worry about the future, The Japanese have the ‘karma’ It means – if it’s going to happen, there’s nothing I can do to stop it. I know my time is limited. And so what? I’ve had a good shot at it.”

‘Being Mortal’ sees how modern medicine has helped prolong and extend people’s lives and shows that there is still more work that needs to be done to create a wholly holistic approach to ensure the choices and expectations of older people are respected and met until the end of their life.

'Being Mortal' is available to buy now.

Mr Gawande has also given the 2014 Reith Lectures for BBC Radio 4 which are avaiable to listen to on the BBCiplayer.