Chapter 1 -The Independent Self
With doctors as parents and his grandparents living in another country, Atul Gawande wasn’t
exposed to old age or age-related illnesses until he was introduced to his girlfriend’s
grandmother. Gawande uses his grandfather in India and his girlfriend’s (now wife’s)
grandmother to compare the Westernized way of caring for the elderly vs. the rest of the world.
Economic development, life expectancy, and shifting changes towards independence have all
shaped how we now deal with providing for the elderly.
Quote: “My father’s father had the kind of traditional old age that, from a Western perspective,
seems idyllic. . . When we ate, we served him first. When young people came into his home, they
bowed and touched his feet in supplication. In America, he would almost certainly have been
placed in a nursing home.”
Question: Compare the care given to your great-grandparents vs. your grandparents. What has
Chapter 2 – Things Fall Apart
In the past, a graph of a person’s health looked like a cliff — smooth sailing until sickness caused
a steep drop off to death. Now, with medical improvements, acute as well as chronic illness can
be controlled creating a more a gradual end. The author examines some of the reasons we age
including “random wear and tear” and genetics. New concerns of aging, beyond physical
symptoms, are saving for retirement and the dwindling number of health care providers.
Quote: Decline remains our fate; death will someday come. But until that last backup system
inside each of us fails, medical care can influence whether the path is steep and precipitate or
more gradual, allowing longer preservation of the abilities that matter most in your life.
Question: What is an illness that persisted in your parent’s lifetime that is now treatable?
Chapter 3 – Dependence
Developments in the industrialized world, including social security and military pensions, have
made poorhouses a thing of the past. But while many of us are no longer limited by financial
restrictions, the housing options available to the elderly can still be problematic. Nursing homes
were born from a need to provide medical care. Unfortunately, this means many of our nursing
homes today are sterile and uninviting. How do we fulfill medical and nonmedical needs of the
elderly while also creating an atmosphere that feels inviting?
Quote: It is not death that the very old tell me they fear. It is what happens short of death —
losing their hearing, their memory, their best friends, their way of life.
Question: Would you consider moving to a 55+ community?
Chapter 4 – Assistance
strain on the primary caregiver. Keren Brown Wilson created the concept of an assisted living
facility as an alternative to a nursing home. She envisioned a community that would allow the
elderly to “live with freedom and autonomy no matter how physically limited they became.”
Instead of keeping with Wilson’s vision, most of today’s assisted living facilities now serve as a
stepping stone between living independently and living in a nursing home.
Quote: In the absence of what people like my grandfather could count on — a vast extended
family constantly on hand to let him make his own choices — our elderly are left with a
controlled and supervised institutional existence, a medically designed answer to unfixable
problems, a life designed to be safe but empty of anything they care about.
Question: Do you think the care of elderly family members should fall to the younger
Chapter 5 – A Better Life
A problem of many nursing homes is they place importance on dependency needs instead of
acknowledging they must also value the existence of each person. When the young doctor Bill
Thomas took over as medical director of Chase Memorial Nursing Home in New Berlin, N.Y.,
he found the institution extremely depressing. He made it his mission to fight the “Three Plagues
of nursing home existence: boredom, loneliness, and helplessness.” By using pets, young
visitors, and plant life Thomas created a space that made the elderly not only happier but “the
number of prescriptions required per resident fell to half that” of a nearby nursing home. Deaths
at Chase Memorial also fell by 15 percent.
Quote:”ONE HUNDRED BIRDS? IN THIS PLACE?” I said, “You’ve got to be out of your
mind!” – Robert Halbert, Administrator of Chase Memorial
Question: What other ways could you combat the “Three Plagues of nursing home existence?”
Chapter 6 – Letting Go
While modern medicine has increased life expectancy and created vaccines that have eradicated
diseases like Polio in the United States, it has also caused us to forget the art of dying. Instead of
finding solace in “centuries of experience, tradition, and language about our mortality” we are
now faced with the question of when to let go.
Quote: In the United States, 25 percent of all Medicare spending is for the 5 percent of patients
who are in their final year of life, and most of that money goes for care in their last couple of
months that is of little apparent benefit.
Question: If you had an incurable illness, would you put efforts into slowing the prognosis or
live your days without medical help?
Chapter 7 – Hard Conversations
Gawande uses his father’s medical issues to showcase why it is important to have conversations
with our doctors, as well as our loved ones, about our health care wishes. By discussing options
early on, patients dealing with incurable illness can feel empowered by their decisions as well as
lessen the feeling of guilt family members may feel from making these decisions alone.
Quote: Tears wet my eyes. I’m a surgeon. I like solving things. But how do I solve this?
Question: Would you feel comfortable having a conversation about your medical wishes with
your family members today?
Chapter 8 – Courage
Gawande once again uses his father’s health struggles to highlight what courage looks like in the
face of death. His father’s end of life care was based on the hard conversations they had earlier.
But no matter how hard we plan, you can never adequately prepare yourself for death. Though
you know it is coming, you must have the courage to face it.
Quote: Courage is strength in the face of knowledge of what is to be feared or hoped.
Question: According to Gawande “one in 35 Dutch people sought assisted suicide.” The author
sees this as a failure of their care programs. Do you agree or disagree?