TIME Books

A Book About Dying Tells You How to Live

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© 2011 Dorann Weber—Getty Images/Moment Open

Quinn Cummings is a writer of three books, Notes From the Underwire, The Year of Learning Dangerously and Pet Sounds.

Atul Gawande's 'Being Mortal' provides a useful roadmap for making life meaningful

In 30 years, there will be as many people over 80 in the United States as there are under the age of 50.

So notes Atul Gawande in his recently published book, Being Mortal, a book I cannot recommend highly enough. This should be mandatory reading for every American. Hell, every global citizen. Yes, it’s about growing old and dying, and the social and ethical consequences of how we treat our aging population, which might not sound like ideal reading while enjoying a pumpkin spice latte and the changing weather. But we’re all going to grow old, if we’re lucky, and most of us will be caring for an aging person at some point in our lives, if we aren’t already. (For years, I’ve been lobbying for the phrase “Sandwich Generation” to be replaced with “Panini Generation,” because anyone living it knows about the heat and pressure coming from both sides.)

Being Mortal is a clear-eyed, informative exploration of what growing old means in the 21st century; it provides a useful roadmap of what we can and should be doing to make the last years of life meaningful for everyone experiencing the aging process up close. I’ve been a fan of Gawande for years. He’s written three other books and is a staff writer for The New Yorker, a practicing surgeon and a professor at Harvard Medical School, so his medical chops are solid. But his writing chops are just as solid, and this book made me do something I usually resist. After about 10 pages, I grabbed the dreaded Hi-Liter from my drawer so I could remember not just useful information but also beautifully crafted prose. One example:

People with serious illnesses have priorities besides simply prolonging their lives. Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others and achieving a sense that their life is complete. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The question therefore is not how we can afford this system’s expense. It is how we can build a health care system that will actually help people achieve what’s most important to them at the end of their lives.

And that’s just one passage. My copy of Being Mortal is crisscrossed with yellow stripes. I won’t be lending this one out any time soon.

Maybe that’s how I coax you into reading a book about death on a lovely autumn day; because a book about aging and dying is, ultimately, a book about how to live. My hope is that the holidays arrive, you’re sitting with your loved ones over the remnants of a big meal, and this book gives you the courage to say out loud: “Tell me how you want to live.”

Quinn Cummings is a writer of three books, Notes From the Underwire, The Year of Learning Dangerously and Pet Sounds. Her articles have been published in, among others, The Atlantic, The Wall Street Journal, TIME, The Huffington Post and Good Housekeeping. She is a passionate animal lover, an indifferent housekeeper and would eat her own hand if you put salsa on it.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Research

How Your Sense of Smell Is Linked to Your Lifespan

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Older adults who suffer an impaired olfactory sense are more likely to die within five years, say researchers

The loss or erosion of an individual’s sense of smell may signal impending death, according to a new study.

Researchers at the University of Chicago found 39% of subjects who failed olfactory sense tests died within a five-year period, compared with 19% of subjects with moderate smell loss and just 10% who retained a healthy sense of smell.

This mean the loss or degradation of the olfactory sense may serve effectively as an “early warning” signal that something has gone very wrong inside the body, says the study published in the journal PLOS One on Wednesday.

“We think loss of the sense of smell is like the canary in the coal mine,” said the study’s lead author Dr. Jayant Pinto. “Our findings could provide a useful clinical test, a quick and inexpensive way to identify patients most at risk.”

The research was conducted in two waves over the course of more than five years and surveyed approximately 3,000 adults.

TIME People

What Price Fame: James Dean Was “Barely a Celebrity” Before He Died

James Dean advice
From the Sept. 3, 1956, issue of TIME TIME

Sept. 30, 1955: James Dean is killed in a California car crash

James Dean’s career picked up considerably after he died.

The budding film star was killed on this day, Sept. 30, in 1955 after crashing his Porsche Spyder en route to a road race in Salinas, Calif., in which he was scheduled to compete. Just 24, he was “barely a celebrity” at the time, according to a 1956 story in TIME, which went on to report that within a year of his death he had gained more popularity than most living actors. Magazine and book publishers looking to memorialize the enigmatic icon were preparing “to jump aboard the bandwagon that looks disconcertingly like a hearse,” the piece proclaimed.

When he died, Dean had acted in only three movies: East of Eden, Rebel Without a Cause, and Giant, only one of which had yet been released. He had worked his way up from smaller to larger roles: from appearing in a Pepsi commercial to working as a “test pilot” for stunts on a TV game show called Beat the Clock — a sort of precursor to Minute to Win It in which contestants competed in absurd timed challenges — to a well-reviewed role as a young gigolo in a Broadway adaptation of Andre Gide’s The Immoralist.

After he died, though, his fame reached new heights. By September of 1956, TIME noted Deans’ bewildering ascent to Hollywood superstardom:

Today he ranks No. 1 in Photoplay’s actor popularity poll, draws 1,000 fan letters a week (“Dear Jimmy: I know you are not dead”) at Warner’s — more than any live actor on the lot. Marveled one West Coast cynic: “This is really something new in Hollywood — boy meets ghoul.” Hollywood’s explanation: Dean not only appeals to a “mother complex” among teenage girls, but his roles as a troubled insecure youth prompted many young movie fans to identify with him.

Business types were eager to cash in on his posthumous popularity. In 1956, the story continued, Dean was still “haunting” newsstands with “four fast-selling magazines devoted wholly to him.”

He hasn’t stopped earning since. Forbes reported that in 2000, Dean’s estate raked in $3 million, very little of which took the form of royalties from his three films. Most came instead from licensing and merchandizing: “The rebellious heartthrob currently hawks everything from Hamilton watches, Lee Jeans, and Franklin Mint collectibles to cards by American Greetings, funneling funds to James Dean Inc., which is run by cousin Marcus Winslow.”

One of the many teenage girls pining for the departed heartthrob wrote to the advice columnist Dorothy Dix in the year after Dean’s death, lamenting, “I am 15 and in love. The problem is that I love the late James Dean. I don’t know what to do.” Dix advised her that time would lessen the sting of love and loss. In this case, however, the platitude’s been proved not entirely true: more than half a century on, society’s love for the late James Dean is still going strong.

Read about James Dean’s legacy here, in TIME’s archives: Dean of the One-Shotters

TIME India

Floods Have Killed 73 in India’s Northeast

People use cycle rickshaws to commute through a flooded road after heavy rains in Guwahati
People use rickshaws to commute through a flooded road after heavy rains in the northeastern Indian city of Guwahati on Sept. 23, 2014 Utpal Baruah—Reuters

Hundreds of thousands of people have been forced to evacuate their homes

Around 73 people have been killed in India’s northeast, after flash floods and landslides hit two states in the region.

A senior government official in Meghalaya told the Associated Press on Wednesday that 35 bodies had been recovered over the past two days with 15 people still missing. Police in neighboring Assam said the floods had claimed 38 lives there.

Hundreds of thousands of people have been forced from their homes in both states mere weeks after flash floods in Kashmir killed over 400 people, about half of them in Pakistan. Local news channel NDTV reported that the army and disaster-response forces have been evacuating people, with authorities setting up 162 relief camps in the worst-affected areas.

The Assam-Meghalaya floods have so far not seen the kind of backlash against alleged government inaction that marked the Kashmir floods.

“We are taking all relief and rescue measures in the flood-hit districts,” said Assam Chief Minister Tarun Gogoi.

TIME

The Deadliest Football Seasons on Record

Notre Dame Fighting Irish
The Notre Dame Fighting Irish run on the field during a game circa 1931 at the Notre Dame Stadium in South Bend, Ind. Collegiate Images / Getty Images

A look back at the years when the sport may have claimed more casualties than ever

In the new issue of TIME, Sean Gregory looks at the risk of brain injury that accompany playing football. It’s a harrowing tale focused on the death of a high-school player.

That risk is a problem that has lurked on the football field since the end of the nineteenth century. “Football killed 40 boys and young men during the 1931 season,” TIME reported in the Dec. 14, 1931, issue. “To approximate that record of deaths it is necessary to go back to 1905 when more than a score of players died and President Roosevelt stopped the roughness of play.” The article continued:

Among this year’s dead 40 were Joseph I. Johnson, 13, of Lafayette, Ind., who shot himself in the abdomen because he could not “make” his grade school team. Another fatality was Coach Ray Pardue. 24, of Statesville, N. C. High School team, cuffed to death by Garfield Jennings, 20, vexed linesman of the Taylorsville, N C. High School, which was playing Statesville High. Almost all the other deaths followed bashings on the football field. Most discussed of the deaths from violence were those of Army’s Richard Brinsley Sheridan (TIME, Nov. 2) and Fordham’s Cornelius Murphy. Murphy, 22, died fortnight ago from a ruptured brain blood vessel. Eleven days prior he had been buffeted into unconsciousness. He was hospitalized for concussion of the brain, released prematurely.

That 1931 record may still stand.

With more than a century of football played throughout the United States, it’s difficult to determine exactly how many deaths are related to the game each year. Early seasons, like the legendarily tough 1909 year, have their high injury counts blamed on lack of protective equipment — but prior to 1931, and especially prior to that 1905 year when Teddy Roosevelt intervened to make the sport safer, it’s hard to find any numbers at all.

Starting in 1931, coaches with joined the Committee on Injuries and Fatalities of the American Football Coaches Association to track football-related injuries and fatalities. The group has issued a report every year since (with the exception of 1942), though its methods of measurement have evolved over the years. It separates direct fatalities (the result of a “traumatic blow to the body,” in the words of the 1966 report) from indirect football-related deaths (in the words of the latest report, “caused by systemic failure as a result of exertion while participating in a football activity or by a complication which was secondary to a non-fatal injury,” eg. heart failure or heat stroke), and counts players at every level from “sandlot” to professional.

The committee counted 49 deaths related to football in 1931–31 direct and 18 indirect. The only year on record between 1931 and 2013 with more direct fatalities was 1968 (36), but that year’s indirect fatalities were lower (12) than 1931. Indirect fatalities were only equal or higher in 1933, 1935, 1936, 1961, 1965 and 2009. Only 1965 manages to tie 1931 for total deaths, leaving them sharing the title of deadliest year.

From the beginning, the point of keeping track was to figure out ways to bring the numbers down. (The reports, organized by a group of people closely linked to the sport, also tend to point out how small the numbers are in terms of percentage of players.) That 1931 article, published shortly before the first fatalities report, suggested a few ideas:

Dr. Beverly Randolph Tucker. Richmond, Va. neurologist, advised President Hoover to appoint a National Commission which would prevent sports becoming too rough for human anatomy to withstand.

Dr. Henry Ottridge Reik, executive secretary of the Medical Society of New Jersey, urged New York, New Jersey and Pennsylvania doctors, who were meeting at Atlantic City last week, to campaign for the complete abolition of college and high school football.

Dr. Reik’s advice seems unlikely to ever be heeded, though his modern descendents are out there. Football is death for some, and a way of life for many.

Read more about the dangers of the game in this week’s issue of TIME: The Tragic Risks of American Football

TIME celebrities

Watch Hugh Jackman Describe The ‘Uplifting’ Experience of Singing at Joan Rivers’ Funeral

He sang "Quiet Please, There's a Lady on Stage"

Joan Rivers’ funeral was held on Sept. 7, and as she wished, it was a star-studded affair with celebrity guests like Sarah Jessica Parker, Howard Stern and Rosie O’Donnell. Rivers had also wanted X-Men star Hugh Jackman to perform at her funeral after seeing him in a musical, The Boy From Oz, 10 years ago. Jackman sang a song from that musical titled “Quiet Please, There’s a Lady on Stage.”

Jackman described the experience on The Tonight Show Starring Jimmy Fallon as “uplifting” and “moving” but also “funny.”

TIME Television

Read the Real 1931 Announcement of That Shocking Death on Boardwalk Empire

TIME had the news before HBO did

The following post contains spoilers for the Sept. 7 episode of Boardwalk Empire.

If you’re a student of history (or reader of Wikipedia), you likely had an idea of what was in store for Giuseppe “Joe the Boss” Masseria when you saw that Boardwalk Empire was skipping forward six years to 1931 for its fifth and final season, which premiered on Sunday.

Here’s how TIME announced, on April 27, 1931, what Boardwalk viewers now know:

April 27, 1931
From the April 27, 1931, issue of TIME

The HBO drama wasted no time in arriving at the New York crime boss’s demise, having him clipped by Bugsy Siegel and another assassin under orders from Lucky Luciano and Meyer Lansky in the season’s very first episode. And because this is Boardwalk Empire, it’s a safe bet that this death of a real-world character will be followed by the deaths of fictional characters (and ultimately other real-world ones as well).

Read James Poniewozik’s review of the final season of Boardwalk Empire here on TIME.com

TIME celebrities

Joan Rivers Gets a Heartfelt Farewell From Whoopi Goldberg, Sarah Jessica Parker, Diane Sawyer and Other Stars

The 81-year-old's funeral services were held in New York City on Sunday

Joan Rivers’ Sunday funeral was a star-studded memorial, featuring performances and heartfelt speeches from some of the 81-year-old comedian’s closest friends.

Rivers’ services were held at Temple Emanu-El on the Upper East Side of Manhattan. Celebrities including Sarah Jessica Parker, Hoda Kotb, Diane Sawyer and Whoopi Goldberg were in attendance. According to PEOPLE, Howard Stern delivered a truly touching speech about his “best friend” Rivers, whom he called a “big sister.”

The New York City Gay Men’s Chorus, Audra McDonald and Hugh Jackman were among the performers.

Read more about Rivers’ funeral at PEOPLE.

TIME Accident

Chicago Church Sorry for Falling Gargoyle That Killed Mom

Chicago Cityscapes And City Views
The Second Presbyterian Church in Chicago, Illinois on April 1, 2011. Raymond Boyd—Getty Images

Second Presbyterian Church remains open

A historic Chicago church apologized Friday to the family of a woman who was killed Thursday when she was struck by crumbling pieces of a gargoyle that fell off the church steeple.

The church said it is “deeply sorry at the death,” Reuters reports. Sara Bean, 34, was walking to lunch with her fiancé Thursday when the gargoyle pieces fell on her. She was a nurse’s aide and a mother of two boys, ages 10 and 14. The fiancé, her longtime boyfriend, is the children’s father.

Second Presbyterian Church, located in the South Loop neighborhood near downtown Chicago, dates from 1873 and is one of the oldest buildings in the city. It moved quickly to put protective scaffolding around the structure, Reuters reports.

The building has no outstanding complaints but in 2011 failed an inspection due to problems that included a failure to maintain exterior walls. After repairs were made that case was dismissed. The church was made a historic landmark last year and will remain open despite the tragedy.

[Reuters]

TIME health

Why Dying Is Easier for Doctors

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BSIP—UIG via Getty Images

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. This piece originally appeared at Zocalo Public Square.

For all the effort they spend fending off the deaths of others, they tend to be fairly serene when faced with their own death

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

To see how patients play a role, imagine a scenario in which someone has lost consciousness and been admitted to an emergency room. As is so often the case, no one has made a plan for this situation, and shocked and scared family members find themselves caught up in a maze of choices. They’re overwhelmed. When doctors ask if they want “everything” done, they answer yes. Then the nightmare begins. Sometimes, a family really means “do everything,” but often they just mean “do everything that’s reasonable.” The problem is that they may not know what’s reasonable, nor, in their confusion and sorrow, will they ask about it or hear what a physician may be telling them. For their part, doctors told to do “everything” will do it, whether it is reasonable or not.

The above scenario is a common one. Feeding into the problem are unrealistic expectations of what doctors can accomplish. Many people think of CPR as a reliable lifesaver when, in fact, the results are usually poor. I’ve had hundreds of people brought to me in the emergency room after getting CPR. Exactly one, a healthy man who’d had no heart troubles (for those who want specifics, he had a “tension pneumothorax”), walked out of the hospital. If a patient suffers from severe illness, old age, or a terminal disease, the odds of a good outcome from CPR are infinitesimal, while the odds of suffering are overwhelming. Poor knowledge and misguided expectations lead to a lot of bad decisions.

But of course it’s not just patients making these things happen. Doctors play an enabling role, too. The trouble is that even doctors who hate to administer futile care must find a way to address the wishes of patients and families. Imagine, once again, the emergency room with those grieving, possibly hysterical, family members. They do not know the doctor. Establishing trust and confidence under such circumstances is a very delicate thing. People are prepared to think the doctor is acting out of base motives, trying to save time, or money, or effort, especially if the doctor is advising against further treatment.

Some doctors are stronger communicators than others, and some doctors are more adamant, but the pressures they all face are similar. When I faced circumstances involving end-of-life choices, I adopted the approach of laying out only the options that I thought were reasonable (as I would in any situation) as early in the process as possible. When patients or families brought up unreasonable choices, I would discuss the issue in layman’s terms that portrayed the downsides clearly. If patients or families still insisted on treatments I considered pointless or harmful, I would offer to transfer their care to another doctor or hospital.

Should I have been more forceful at times? I know that some of those transfers still haunt me. One of the patients of whom I was most fond was an attorney from a famous political family. She had severe diabetes and terrible circulation, and, at one point, she developed a painful sore on her foot. Knowing the hazards of hospitals, I did everything I could to keep her from resorting to surgery. Still, she sought out outside experts with whom I had no relationship. Not knowing as much about her as I did, they decided to perform bypass surgery on her chronically clogged blood vessels in both legs. This didn’t restore her circulation, and the surgical wounds wouldn’t heal. Her feet became gangrenous, and she endured bilateral leg amputations. Two weeks later, in the famous medical center in which all this had occurred, she died.

It’s easy to find fault with both doctors and patients in such stories, but in many ways all the parties are simply victims of a larger system that encourages excessive treatment. In some unfortunate cases, doctors use the fee-for-service model to do everything they can, no matter how pointless, to make money. More commonly, though, doctors are fearful of litigation and do whatever they’re asked, with little feedback, to avoid getting in trouble.

Even when the right preparations have been made, the system can still swallow people up. One of my patients was a man named Jack, a 78-year-old who had been ill for years and undergone about 15 major surgical procedures. He explained to me that he never, under any circumstances, wanted to be placed on life support machines again. One Saturday, however, Jack suffered a massive stroke and got admitted to the emergency room unconscious, without his wife. Doctors did everything possible to resuscitate him and put him on life support in the ICU. This was Jack’s worst nightmare. When I arrived at the hospital and took over Jack’s care, I spoke to his wife and to hospital staff, bringing in my office notes with his care preferences. Then I turned off the life support machines and sat with him. He died two hours later.

Even with all his wishes documented, Jack hadn’t died as he’d hoped. The system had intervened. One of the nurses, I later found out, even reported my unplugging of Jack to the authorities as a possible homicide. Nothing came of it, of course; Jack’s wishes had been spelled out explicitly, and he’d left the paperwork to prove it. But the prospect of a police investigation is terrifying for any physician. I could far more easily have left Jack on life support against his stated wishes, prolonging his life, and his suffering, a few more weeks. I would even have made a little more money, and Medicare would have ended up with an additional $500,000 bill. It’s no wonder many doctors err on the side of overtreatment.

But doctors still don’t over-treat themselves. They see the consequences of this constantly. Almost anyone can find a way to die in peace at home, and pain can be managed better than ever. Hospice care, which focuses on providing terminally ill patients with comfort and dignity rather than on futile cures, provides most people with much better final days. Amazingly, studies have found that people placed in hospice care often live longer than people with the same disease who are seeking active cures. I was struck to hear on the radio recently that the famous reporter Tom Wicker had “died peacefully at home, surrounded by his family.” Such stories are, thankfully, increasingly common.

Several years ago, my older cousin Torch (born at home by the light of a flashlight–or torch) had a seizure that turned out to be the result of lung cancer that had gone to his brain. I arranged for him to see various specialists, and we learned that with aggressive treatment of his condition, including three to five hospital visits a week for chemotherapy, he would live perhaps four months. Ultimately, Torch decided against any treatment and simply took pills for brain swelling. He moved in with me.

We spent the next eight months doing a bunch of things that he enjoyed, having fun together like we hadn’t had in decades. We went to Disneyland, his first time. We’d hang out at home. Torch was a sports nut, and he was very happy to watch sports and eat my cooking. He even gained a bit of weight, eating his favorite foods rather than hospital foods. He had no serious pain, and he remained high-spirited. One day, he didn’t wake up. He spent the next three days in a coma-like sleep and then died. The cost of his medical care for those eight months, for the one drug he was taking, was about $20.

Torch was no doctor, but he knew he wanted a life of quality, not just quantity. Don’t most of us? If there is a state of the art of end-of-life care, it is this: death with dignity. As for me, my physician has my choices. They were easy to make, as they are for most physicians. There will be no heroics, and I will go gentle into that good night. Like my mentor Charlie. Like my cousin Torch. Like my fellow doctors.

Ken Murray, MD, is Clinical Assistant Professor of Family Medicine at USC. This piece originally appeared at Zocalo Public Square.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

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