A few years ago, my doctor said I had age-appropriate arthritis. I was outraged. He might as well have said I had age-appropriate Alzheimer’s or age-appropriate cancer.
Of course, I understood rationally that the language he used was entirely appropriate. We all age, and along with it come the thousand natural shocks that flesh is heir to. Shakespeare knew that 400 years ago. I also knew that natural was the operative word. The Grand Canyon has age-appropriate erosion.
I just didn’t like having the notion applied to me. so this little vignette contains two big lessons. First, we all erode and eventually die. The Bible put our sell-by date at three score and ten, which means I am living on borrowed time. Lesson two, however says, I’m different. I’m special. The rules don’t apply to me. Or shouldn’t. It isn’t fair.
The first lesson is that rational. scientific facts exist. The second is that we are not rational. We don’t go by statistics and facts but by stories, narratives, magical thinking and naked self-interest. And as the heroes of our own sagas, we want not just a happy ending, but no ending.
A third lesson results from the mismatch between facts and magic. We deny death. We don’t even like to hear the word. We pass away or go to a better place. We regard death as an affront, an outrage, an injustice, an error, a plot. This is an expensive delusion.
A substantial percentage of all healthcare dollars in this country are spent on the last little bit of life. One statistic says 13% of Medicare dollars are spent on the last year of life, but that doesn’t include long term care or home health care. A more realistic accounting suggests that as much as 30% of all medical expense comes in the last year of life and a third of that, a full 10%, in the last month.
As the large baby boomer cohort ages, we are going to beggar our children and grandchildren if such spending isn’t controlled. The mandated spending on the elderly is already shortchanging spending for preventative medicine for the young so we can prolong the agony of the old. But any attempt to adjust health priorities is met with stiff resistance. The entire medical-industrial complex profits from more, not less care for the aged. And doctors are trained to intervene. Though Hippocrates said,
“ First, do no harm,” modern medicine says” Don’t just stand there, do something billable.”
When Obamacare was being created, a tiny attempt to educate gravely ill patients and their families was proposed. Doctors would be reimbursed for spending time counselling deathly ill patients about living wills, advance directives, and end-of-life care alternatives to more procedures, more pills and more misery prolongation.
Anyone who has witnessed the end of a loved one is only too aware of HAI, (hospital acquired infections), pharmaceutical side effect and drug interactions, and POCD (postoperative cognitive dysfunction). When problems acquire their own acronyms, they aren’t rare.
Enemies of Obamacare, including Sarah Palin, described such decent, rational, honest counselling for end stage patients as Death Panels, with some shameless partisan lunatics like Virginia Foxx (R-NC) even arguing the government was conspiring to put old people to death.
Using the word death doomed the endeavor. So, we retain a system that strives to maintain life at all costs, and at a gigantic profit, no matter how expensive for society, pointlessly cruel for patients, and agonizing for conflicted families.
The distinguished medical professor, policy guru, and ethicist Ezekiel Emanuel recommends an alternative course. He plans to cease all routine testing and medicating at 75, including flu shots, PSA tests and colonoscopies because they are liable to find reasons to do unnecessary procedures. He also plans to decline heroic treatment in the case of dire cancer, lung, heart, kidney or dementia diagnoses. He will also host his own memorial service at 75, so he can attend and enjoy the event.
Eccentric, you may argue, but he argues that we may be living longer – 76 for men on average and 81 for women – but that doesn’t mean our quality of life is better. In fact, we have increased our longevity at the expense of extending the number of years we live with functional disabilities that cause us to be a burden to ourselves and others.
Will he have the fortitude to follow his own advice? Will any of us? A huge medical apparatus as well as our own fear and misplaced optimism encourage the resort to extreme measures, but maybe Zeke is right, that we should respond to medicinal care at the end in the same way Nancy Reagan said we should respond to non-prescription drugs, and Just Say No. When the jig is up, it’s time to quit trying to dance.
An orthopedic doctor I consulted recently was talking to me about this issue and said he had hoped John McCain, whose diagnosis is just the sort that one should accept as unappealable, would have used the occasion to counsel others to go gently, not expensively, into that good night. He was disappointed that a teachable moment had been squandered.
Ironically, this was in the middle of proposing an operation on arthritic bone spurs in my thumb that would take up to a year to get over and at best would reduce my pain but never restore full function. Thus, plays out Act Three in the drama, choosing the lesser of two evils.