“Yet within a few years, when I came to experience surgical training and practice, I encountered patients forced to confront the realities of decline and mortality and it didn’t take them long to realize how unready I was to help them.” 

Gawande reflects on his earliest moments in medicine, when he was first interacting with patients whose conditions were terminal. He realizes that those patients inevitably knew two things—firstly, that there was little that medicine could really do for them, and, secondly, that he as a doctor was emotionally and professionally ill-prepared to help his patients through the process of confronting death.

“Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.” 

Throughout the book, Gawande works towards establishing a more plausible, coherent vision for how people might live life in a meaningful way right up until they die. He thinks the main barrier to achieving this plan is modern society’s reluctance to really face death and express the wishes and fears that we have about that process.

“In the past, surviving into old age was uncommon and those who did survive served a special purpose as guardians of tradition, knowledge and history. They tended to maintain their status and authority as heads of the household until death.” 

Gawande’s grandfather remains a revered elder until his death at age 109. He makes family decisions, conducts business, and comes and goes as he pleases. This, Gawande acknowledges, is quite the opposite of how elders are treated in modern American society. Alice Hobson is a more typical example of an American elder who lives alone for as long as she can until being placed in a nursing home, so her family can find peace of mind knowing others are caring for her around the clock.