Being Mortal by Atul Gawande

I recently finished reading Being Mortal by Atul Gawande and the timing was eerily perfect. My 83 year old grandfather has been struggling with health issues which made reading the book easier to relate to and comprehend. I was too young to remember much about the nursing homes my great grandmother and grandmother were in, but with my grandfather I’m now questioning what is the best care for him, what other options are available, and how he feels about his situation.

Going back to the book itself, it hits on a wide variety of topics, all related to aging and death. The author has several examples of how different cultures handle aging that paint a picture of how we can improve here in the U.S. While its very difficult for our current society to live with their parents until they die, its not entirely impossible. In the land use world, we have finally returned to the idea of the “mother in-law unit” which offers a completely separate space for aging parents to live, while in close proximity to the family. This situation offers the best of both worlds—parents do not have to go to a nursing home, but do not impose on their children and they have their own space. This only works until the parent can no longer make it without assistance. As I have found recently, it can be very expensive to have a nurse come to the home daily to care for an aging parent, leaving this task to the family who often do not have time to be home the necessary amount to take care of them.

A solution offered in the book is the assisted living facility—the original style of assisted living—not what for-profit companies have redesigned it to be. Decades ago the assisted living facility was built to allow aging people to live in a communal building, but were not mandated by the schedules and routines enforced in today’s facilities. They had freedom to make their own decisions. They could eat when they wanted to, take their medications only if they wanted, and sleep as late as they desired. The benefit was medical staff was there to help when necessary. We need housing that allows this type of freedom, so our elders do not feel like they are giving up all control.

Another option in the book was a neighborhood support program like Beacon Hill Village in Boston or Athens Village in Ohio. Residents pay an annual fee ($400 per year in one instance) for services that allow them to stay in their own home. The company hires a handyman, nurse, coordinator, and transportation, all available to the members when they need it. They are free to carry on their lives without drastically altering their routines. I wonder how much longer my grandpa could have stayed in his home if this were available where he lived.

One problem with this type of service is the actual home itself. Often, the houses our elderly are living in are not safe, nor do they make it easy for them to navigate their daily routines. In my grandparents case, they lived in a split level, so stairs were required to come and go or do laundry. New construction nationally is focusing on building one-level, zero entry homes. These homes are void of steps that can cause a more unstable adult to fall and break a hip, a sure way to end up in a nursing home permanently. These types of homes can offer a longer independent life for aging people, especially when combined with to the types of services available in Beacon Hill Village. In my job I’m often conducting housing surveys and time and again, the number one housing type for 55+ individuals always comes back as a small independent home with some services provided. The traditional assisted living facility is almost always dead last.

As the book describes, its important for aging people to have some responsibility as it creates purpose for the elderly. In one example, the author describes a nursing home that added a few birds to each residents room. Just the simple responsibility of watching their activity and reporting back to the nursing staff improved the physical and mental health of most of the patients. One of the only things I remember from my great grandmothers nursing home was a large glass enclosure with birds at the end of the hall. While I’m sure it was nice to look at and listen to, it really didn’t have benefits beyond that. I doubt residents had any part in caring for the birds.

I was able to draw direct parallels for the lessons in the book to my daily work in planning for cities. Based on the authors teachings, we should not be building assisted living and nursing homes out on the edge of town, but at the heart of the community. Putting them in a space like the town square allows them to easily maintain interaction and independence. They get the care they need with the ability to walk a short distance for coffee or to the library. Mixing them with other uses in the same building is important as well. Many communities are experimenting with assisted living facilities that have daycare’s within. What better way to give residents a purpose than to pair them with young children to watch over. Last and most important, by building homes that are fit for aging individuals, they can downsize into a more comfortable home, freeing up the homes for young families that need the extra space and can live with the stairs.

As in medicine, the topic of listening to the real needs of the elderly population, is all to forgotten in the field of planning. We need to make more of an effort to think about residents reaching and exceeding the age of 55 and what they will need to live a meaningful and engaged life. As planners, we can encourage or prohibit this through zoning and land use regulations. We should allow mixed uses, encourage location near activity centers, and require the buildings themselves to reflect an open and engaging environment. It’s what the aging clearly desire and what they deserve.