In medical school, the author was taught to save lives, not care for the dying.
“Medical professionals concentrate on repair of health, not sustenance of the soul. Yet -- and this is the
painful paradox -- we have decided that they should be the ones who largely define how we live in our waning
Death is not a medical failure but an inevitable part of life, yet doctors still struggle to comprehend
this, often causing great suffering by pursuing treatments with little benefit as patients deteriorate. The author
sets out to examine how the experience of mortality has changed in modern times and how care for the dying can be
“Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural
order of things.”
The author's wife's grandmother, Alice, lived independently into old age, in contrast with the author's
grandfather, Sitaram, in India, who was entirely cared for by his family.
While Sitaram's situation allowed him to retain direction over his farm and business affairs into extreme
old age, the expectation of family care put burdens on his children's freedom and mobility.
As life expectancy rose in the 20th century, more elderly people accumulated enough wealth to maintain
independence from their children, enabled by pensions, retirement programs, and elder services, though ultimately
independence fails for even very healthy seniors like Alice.
The shift toward independent living allows more freedom and options for both young and old, but does not
resolve the necessity of care when infirmities like memory loss, injuries from falls, and inevitable health issues
Though many believe they want the traditional family care Sitaram received, historical trends show people
generally prefer autonomy and separation for both parents and children when economic independence is
Normal aging brings lowered lung capacity, hardened blood vessels, shrinking brains, bad teeth, slower
bowels, etc. -- changes doctors can manage, not cure or reverse.
About 350,000 Americans fall and break a hip every year.
Modern medicine extends lifespans but creates challenges around managing the increasing number of older
In 1945, most US deaths occurred at home. In the 1980s it dropped to 17%, since adult children are now more
spread out and busy.
“Modernization did not demote the elderly. It demoted the family. It gave people -- the young and the old --
a way of life with more liberty and control, including the liberty to be less beholden to other generations. The
veneration of elders may be gone, but not because it has been replaced by veneration of youth. It's been replaced
by veneration of the independent self.”
Geriatricians specialize in helping older people maintain quality of life but their field is often
Case studies show geriatric care can help manage chronic conditions and prevent disability.
Society needs to better prioritize geriatric care and train more doctors to handle the needs of an aging
Finding purpose and maintaining independence are key for a good quality of life in old age.
Felix cares devotedly for his declining wife Bella, but her cascading losses -- vision, hearing, memory --
ultimately sever communication and force separation to a nursing home, where she falls, breaks her legs, and dies,
leaving Felix bereft.
Alice dreads leaving home for assisted living, and once forced into the nursing wing after falls, she feels
imprisoned -- her privacy and independence gone, as safety regulations strip away autonomy and meaning. Alice
ultimately dies after months resisting care, seeming to choose death over merely existing in custody.
In 1980, 83-year-old Harry Truman defied evacuation warnings and stayed put at his home below Mount Saint
Helens. Unwilling to abandon his life, he gambled with eruption, ultimately perishing when the volcano roared to
life. His story embodies the fierce independence some seek, and that safety and longevity come at the cost of
control over one's last days.
Though far better than poorhouses, nursing homes were an accident of history, created to clear hospital beds
and exploit Medicare. Nursing homes were never meant for living, as they isolate people from what they still cling
When Lou's declining health after his wife's death forces him to leave home, daughter Shelley struggles to
care for him amidst her job and family, so they compromise on an assisted living facility, yet it proves lonely
and grim. Though founded as an empowering alternative to nursing homes, assisted living has often become a halfway
house to institutionalization, with rigid rules that cater more to worried children than happy parents.
Children making choices for declining parents face an impossible tension between safety or happiness, and
protecting our loved ones or controlling them.
Research suggests that older people prioritize close relationships and the present pleasures over new
relationships and experiences. This might come from a sense of limited time, as when horizons contract, focus
shifts from future opportunities to present meaning.
“How we seek to spend our time may depend on how much time we perceive ourselves to have.”
Research shows that old people are generally happier and found life more emotionally satisfying and
Bill Thomas transformed Chase Memorial Nursing Home by introducing pets, children, and plants to combat the
three plagues of nursing homes -- boredom, loneliness, and helplessness.
Medication needed and deaths both fell after these practices were introduced.
Having something to care for gives residents a reason to live and improves their mental and physical
Philosopher Josiah Royce theorized people need causes beyond themselves, big or small, to find meaning.
Institutions and professionals need to respect and support individual agency even in old age, allowing
people to maintain a connection to their identities and purpose for as long as possible.
Successful models feature smaller housing units, personalized care, and opportunities for socialization and
“The only way death is not meaningless is to see yourself as part of something greater: a family, a
community, a society. If you don't, mortality is only a horror.”
When Sara's terminal lung cancer finally leaves her struggling to breathe, her doctor suggests that she
prepares for the end, avoiding more chemotherapy, ventilation and tests, so she can die peacefully at home.
Doctors need to navigate the difficult balance between offering hope and acknowledging the limitations of
medicine, helping patients shift their focus to quality of life rather than prolonging death when appropriate.
Doctors should ask terminally ill patients what activities matter the most to them, then suggest procedures
with those priorities in mind, even if they could shorten life.
As a brave general leads troops wisely, so must doctors help terminal patients fight the winnable battles --
for pain relief, family time, or one last chocolate ice cream -- while knowing when the war against mortality
itself is lost.
Though contentious and illegal in many places, ideally assisted suicide would be an option to those who are
suffering excruciating pain.
Open communication about end-of-life wishes is crucial for patients and families to make informed decisions
and avoid unnecessary suffering.
Where doctors usually over-treat, the field of hospice focuses on maximizing comfort and awareness when
little time is left.
“Those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier,
experienced less suffering at the end of their lives -- and they lived 25% longer.”
“You live longer only when you stop trying to live longer.”
25% of US healthcare spending goes to the treatment for last-year-of-life patients, but they account for
only 5% percent of total patients.
The author's father, facing a tumor, decides to prioritize quality of life over aggressive treatment, opting
for surgery only when his symptoms worsen. Through hospice care and palliative support, he manages his pain and
retains control over his remaining time. In the end, the author helped his father die on his own terms, focusing
on minimizing unnecessary suffering while prioritizing comfort and family.
We need to talk honestly about aging, illness and death with our loved ones, before it is too late to make
informed and meaningful choices. By facing death openly, we can reduce its suffering.
Ask what trade-offs we are willing to make at the end of our lives, and what makes life worth living for
Accepting our mortality can empower us to live authentically and choose our dying role.
Peg, the author's daughter's piano teacher who had terminal cancer, decided to use her final days to give
lessons to her students.
Medicine should prioritize well-being over mere survival and drawing out death. Focus needs to be on
understanding patients' hopes and fears to guide treatment choices.
“A few conclusions become clear when we understand this: that our most cruel failure in how we treat the
sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living
longer; that the chance to shape one's story is essential to sustaining meaning in life; that we have the
opportunity to refashion our institutions, our culture, and our conversations in ways that transform the
possibilities for the last chapters of everyone's lives.”
While the author's father ultimately succumbed to disease, he accepted life's limitations and died on his
own terms, leaving a sense of peace for his family. As the author's family spread his father's ashes in the Ganges
River, they feel grateful that he now has found eternal salvation and is connected to something larger.