Francesco Iannuzzella wrote the summary for chapter 5.

Chapter Five: A Better Life

In order to maintain the integrity of their social network, and enjoy a higher quality of life, most elderly people would prefer to remain in their homes as long as possible. Nevertheless, at some time during their life, many of them will be admitted to a nursing home.

Traditionally, nursing homes have been organized to provide an efficient medical care to frail and impaired individuals with little or no attention given to quality of life. Fortunately, the deepest changes usually start on a very small scale and one single successful experience can radically change the way of doing something.

In the beginning of chapter five, Gawande describes the biography of one of these heroes, Bill Thomas, a man who rewrote the manual on how nursing homes operate.

Bill Thomas’s experience began in the early 1990s when he got a new job as medical director of Chase Memorial Nursing home in the town of New Berlin, NY. He was only thirty-one with little or no experience in eldercare. With his newcomer’s eyes, Bill began to question the basic assumptions all had taken for granted since then.

He identified “The Three Plagues” of nursing home existence:

boredom
loneliness, and
helplessness.

Then, he tried to fix them experimenting a new approach to eldercare. His aims were clear: he wanted to replace boredom with spontaneity, loneliness with companionship, and helplessness with a chance to become involved in caring for another being. At the beginning, he didn’t make a great change in everyday Chase Memorial healthcare practice, but he adopted an easy and effective approach to bring life to its inhabitants: he introduced a lot of pets, gardens and children to the nursing home.

“He said, “Now, what about cats?”
I said, “What about cats?” I said, “We’ve got two dogs down on the paper.”
He said, “Some people aren’t dog lovers. They like cats.”
I said, “You want dogs AND cats?”
He said, “Let’s put it down for discussion purposes.”
I said, “Okay. I’ll put a cat down.”
“No, no, no. We’re two floors. How about two cats on both floors?”
I said, “We want to propose to the health department two dogs and four cats?”
He said, “Yes, just put it down.”
I said, “All right, I’ll put it down. I think we’re getting off base here. This is not going to fly with them.”
He said, “One more thing. What about birds?”
I said that the code says clearly, “No birds allowed in nursing homes.”
He said, “But what about birds?”
I said, “What about birds?”
He said, “Just picture—look out your window right here. Picture that we’re in January or February. We have three feet of snow outside. What sounds do you hear in the nursing home?”
I said, “Well, you hear some residents moaning. You possibly hear some laughter. You hear televisions on in different areas, maybe a little more than we’d like them to be.” I said, “You’ll hear an announcement over the PA system.”
“What other sounds are you hearing?”
I said, “Well, you’re hearing staff interacting with each other and with residents.”
He said, “Yeah, but what are those sounds that are sounds of life—of positive life?”
“You’re talking birdsong.”
“Yes!”
I said, “How many birds are you talking to create this birdsong?”
He said, “Let’s put one hundred.”
“ONE HUNDRED BIRDS? IN THIS PLACE?” I said, “You’ve got to be out of your mind!”

The results were extraordinary:

The number of prescriptions halved
With a particular reduction in the use of psychotropic drugs
Mortality fell about 15%.

This was the starting point for a larger program, named Eden Alternative, which over the last 20-years de-institutionalized nursing homes and ultimately lead to the so-called Green House project. Since the first Green House was built in Tupelo, Mississipi, in the year 2000, more than 150 Green Houses have been built in twenty-five states. With no more than twelve residents each, all Green Houses are small and communal with a physical environment made to preserve quality of life, self-sufficiency, privacy, and dignity.

How to explain the Eden Alternative success?

To answer this question, Gawande cites an American philosopher, Josiah Royce (1855-1916), who believed that in order to live a worth living we need loyalty, i.e. a dedication to a cause beyond ourselves. It doesn’t matter if this cause is small (as small as the care for a pet) or large, what matters is that is such a cause provide meaning to one's life. We all need loyalty, and elderly people need it even more.

“The elderly need loyalty to give meaning to both their life and their death.”

They need loyalty to give meaning to both their life and their death. With aging, simple pleasures, we all take for granted during our adulthood, may become a source of loyalty, a comfort to our pain. To testify to this truth, Gawande reports the interviews tof nursing home residents he met, whose quality of life strictly depends upon simple pleasures: living in a private room, going to the cinema, reading Fifty Shades of Grey, using a computer, preserving social interactions.

Gawande describes his experience visiting two different projects in the Boston area. The first one, it is a new human size retiring community called NewBridges on the Charles with great financial resources due to substantial philanthropic support. The second project is a subsidized apartment building (Peter Sanbord Place) for low-income elderly people, whose director Jacquie Carson deeply changed to allow her residents to continue to live their own lives.

The chapter ends by returning to the story of Lou Sanders who has deteriorated to the point where he no longer can live in assisted living and is admitted to a nursing home. However, he enters a Green House with private rooms and a thoroughly de-institutionalized philosophy. He rapidly adapts and explains that he knew it was the place for him when he saw that all the rooms were single. Little things can make all the difference.