Tuesday, October 31, 2017

Being Mortal, by Atul Gawande

here is a famous story in the Mahabharata concerning Yayati, one of the ancestors of the Pandavas and Kauravas. Because of a curse, he lost his youth, yet yearned for it. He asked his sons to exchange his old age for their youth. All but Puru - the youngest - refused. Yayati and Puru swapped their youths. Yayati had his fill of desires, and at the end of long period of time, realized there was no end to desires. He returned Puru his youth, and renounced the kingdom to spend his last days as an ascetic.

Long as youth may be, it still has to give way to old age, and finally death. Not described in this ancient Hindu epic are details of how Yayati actually spent his last days. How did the infirmities of his last days afflict him? How did the end come? We don't know. What medicine is able to tell us today is how the body ages, wears down, and breaks down. Sometimes it can be repaired, sometimes it cannot. Even parts and limbs repaired break down, never to function again. Aging is programmed into the body.
"Inside skin cells, the mechanisms that clear out waste products slowly break down and the residue coalesces into a clot of gooey yellow-brown pigment known as lipofuscin. These are the age spots we see in skin. When lipofuscin accumulates in sweat glands, the sweat glands cannot function, which helps explain why we become so susceptible to heat stroke and heat exhaustion in old age."
Old age may have been synonymous with wisdom in olden times. In India, for example, someone with great wisdom was called 'old'. A famous example is the child prodigy Ashtavakra. Old age could have signified wisdom in an era when the average lifespan was no more than thirty years. To survive into the fifties and sixties meant one had done several things correctly, even if by accident. Where knowledge was transmitted orally, and the written word could travel only as fast as a horseback rider, a person who had lived through one generation was worthy of veneration and a source of wisdom. Not any longer.
"The eyes go for different reasons. The lens is made of crystallin proteins that are tremendously durable, but they change chemically in ways that diminish their elasticity over time—hence the farsightedness that most people develop beginning in their fourth decade. The process also gradually yellows the lens. Even without cataracts (the whitish clouding of the lens that occurs with age, excessive ultraviolet exposure, high cholesterol, diabetes, and cigarette smoking), the amount of light reaching the retina of a healthy sixty-year-old is one-third that of a twenty-year-old."
Therein lies the existential dilemma of the modern age. How does one live when life itself is on a path of terminal decline? Do you try and prolong life with the aid of modern medicine and technology? Do you put off death? Yes, you can. But can you put off dying? That, the author remarks, is a word that he isn't even sure what it means anymore. Consider this:
"I was once the surgeon for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and kidney failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented open her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and she stabilized. After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require weeks of twice-a-day dressing changes and cleansing in order to heal. She would not be able to eat. She would need a tracheostomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life."
Yes, the woman is alive, but is she living? Standard medicine seeks to prolong life, while hospice care, the author tells us, means allowing patients to have a fuller life, even if it is shorter. It is, in many ways, a decision to choose between having a technically longer life, but often without cognition, control, and free will, and between having a shorter life, but one which there is a modicum of awareness and control. The choice is not easy, however.

The bones soften while the arteries harden - the body itself ages in ways that are ironical, if nothing else. The effects of aging are felt in a most non-linear manner. The degradation of the body and mind is not slow, at least in its effects. A gradual wearing away of limbs is followed by a rapid, irreversible decline. This moment of terminal decline has been pushed further and further out, thanks to the wonders of modern science, but it can still not be delayed infinitely. Unlike a century or so ago, when any adverse event - sometimes even what would be considered a minor ailment today - could lead to a rapid worsening and followed as quickly by death, today the pattern looks somewhat different. We fall ill, and we recover, and our health fails in some other way, and we recover, till such time as there is no recovery.
"Our functional lung capacity decreases. Our bowels slow down. Our glands stop functioning. Even our brains shrink: at the age of thirty, the brain is a three-pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room. That’s why elderly people like my grandfather are so much more prone to cerebral bleeding after a blow to the head—the brain actually rattles around inside. "
People don't like dying. We want to live for as long as we can. How long that is, or should be, we don't know. What we do want, however, is a chance. If that chance means trying out a new, experimental drug, then so be it. If it means invasive medical procedures to prolong life, so be it. What we do not bargain for is the loss of the ability to live beyond a vegetative state. If we did, would we make the decision to not prolong life beyond that stage? Probably yes. But what is that line, that point of no return? Who takes responsibility for deciding it is time?
"... an almost eighty-year-old woman at the end of her life, with irreversible congestive heart failure, who was in the ICU for the second time in three weeks, drugged to oblivion and tubed in most natural orifices as well as a few artificial ones. Or the seventy-year-old with a cancer that had metastasized to her lungs and bone and a fungal pneumonia that arises only in the final phase of the illness. She had chosen to forgo treatment, but her oncologist pushed her to change her mind, and she was put on a ventilator and antibiotics. Another woman, in her eighties, with end-stage respiratory and kidney failure, had been in the unit for two weeks. Her husband had died after a long illness, with a feeding tube and a tracheostomy, and she had mentioned that she didn’t want to die that way. But her children couldn’t let her go and asked to proceed with the placement of various devices: a permanent tracheostomy, a feeding tube, and a dialysis catheter. So now she just lay there tethered to her pumps, drifting in and out of consciousness."
Take the case of Sara, who was diagnosed with lung cancer when thirty-nine weeks pregnant. Her cancer, when detected, had metastasized, spread to "multiple lymph nodes in her chest and its lining", and was inoperable. But chemotherapy was an option, "notable a drug called erlotinib, which targets a gene mutation commonly found in lung cancers of female nonsmokers". What are the side-effects of erlotinib? It produces "an itchy, acne-like facial rash and numbing tiredness. She also underwent a needle drainage of the fluid around her lung, but the fluid kept coming back and the painful procedure had to be repeated again and again. So a thoracic surgeon was called in to place a small permanent tube in her chest, which she could drain by turning a stopcock whenever fluid accumulated and interfered with her breathing." Sara was switched to a more conventional chemotherapy treatment, "with two drugs called carboplatin and paclitaxel." That produced an "extreme" allergic reaction, and she was then switched to  "a regimen of carboplatin plus gemcitabine." When even that failed, she was switched to drug called pemetrexed. That also failed.

If life were not so precious to us, no baby would cry its lungs out on being born, building strength to breathe on its own. And live. If life was not imprinted on ourselves, we would not be born with the clasping or gag-reflexes at birth. They are there because they helped us live.

A good book does not give us answers. It makes us think. A great book actually makes us like the process of thinking. This book, by Atul Gawande, is one such great book. Neither do the details of aging and mortality overwhelm the reader, nor do the struggles and tribulations of the dying depress. Each chapter is self-contained, but an integral part of the story that the book tells us. A story about us.

Being Mortal: Medicine and What Matters in the End, by Atul Gawande

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© 2017, Abhinav Agarwal (अभिनव अग्रवाल). All rights reserved.