Atul Gawande has produced a must-read book on dealing
with our inevitable mortality: Being Mortal: Medicine and What Matters in the End. Gawande, a practicing
surgeon and an excellent author and commenter on medical issues, is appalled by
the way we have allowed the act of dying be framed not as a very personal
social issue, but as a medical issue.
“You don’t have to spend much
time with the elderly or those with terminal illness to see how often medicine
fails the people it is supposed to help.
The waning days of our lives are given over to treatments that addle our
brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes
and intensive care units—where regimented, anonymous routines cut us off from
all the things that matter to us in life.
Our reluctance to honestly examine the experience of aging and dying has
increased the harm we inflict upon people and denied them the basic comforts
they most need. Lacking a coherent view
of how people might live successfully all the way to their very end, we have
allowed our fates to be controlled by the imperatives of medicine, technology,
and strangers.”
For those who are in a “fragile” state and unable to care
for themselves, there are better options than warehousing them in facilities
modeled on penitentiaries. Some patients may wish to experience any pain and
discomfort in order to try and squeeze a few more months out of their lives;
others might wish to spend their last few months under palliative care in their
own homes where they can socialize with their friends and relatives while they
settle their affairs. Too often this latter
option is not presented to the terminally ill by the medical community.
Gawande provides numerous examples of how the healthcare
industry can provide better service to aged and seriously ill patients, as well
as advice for patients who must take the time to seriously consider what they
want out of the remaining life they have.
Gawande also provides a description of the aging process
that is useful to all of us as we grow older and must deal with increasing
decrepitude of ourselves or others. This
aging process will be the subject here.
We are told that there are two main hypotheses that
attempt to explain the physical process of aging. The traditional explanation is based on the
notion that the performance of various organs and components of our bodies, and
their backups, degrade over time until some critical level of malfunction is
reached and the body is no longer viable—with multiple organ failures quickly
following. This is what is known as
dying of old age.
A more recent theory holds that humans are programmed
genetically to wind down over a more or less standard time period. One can make evolutionary arguments why a
finite lifetime would be of value to a given species. This hypothesis is also attractive to some
because it provides hope that there is some physical process that controls our
life spans and that process might be modified to produce longer lives. Scientists have been able to demonstrate that
longer lifetimes can be produced in some species by introducing genetic changes.
Gawande is a believer in the wearing out hypothesis. For a programmed lifetime to exist it would
have to have been favored via natural selection. We clearly have the capability to live to
near 100 if we are able to avoid early death by disease or injury. However, all data indicates that our
ancestors rarely, if ever, reached such ages.
Consequently, it is not clear how natural selection might have
programmed in such a long lifespan. Most
selection is based on the survivability of offspring. It is difficult to explain how a potential
longevity of near 100 years can affect the survivability of offspring when typical
longevities might be only 20-30 years.
An even more compelling counter to the genetically
programmed hypothesis resides in inheritance data.
“….only 3 percent of how long
you’ll live, compared with the average, is explained by your parents longevity;
by contrast, up to 90 percent of how tall you are is explained by your parents’
height. Even genetically identical twins
vary widely in life span: the typical gap is more than fifteen years.”
Gawande provides us with a list of the various
degradations and breakdowns that occur as we age. The elderly need to know what has happened to
them, and the young need to understand that it will happen to them as well.
Perhaps the first observation is the graying of our hair.
“Hair grows gray….simply because
we run out of the pigment cells that give hair its color. The natural lifecycle of the scalp’s pigment
cells is just a few years. We rely on
stem cells under the surface to migrate in and replace them. Gradually, however, the stem-cell reservoir
is used up. By the age of fifty, as a
result, half of the average person’s hairs have gone gray.”
At about the same time, we begin to notice that we are no
longer able to read without lens corrections and start surrounding ourselves
with brighter light sources.
“The lens is made of crystalline
proteins that are tremendously durable, but they change chemically in ways that
diminish their elasticity over time—hence the farsightedness that most people develop
in their fourth decade. The process also
gradually yellows the lens. Even without
cataracts….the amount of light reaching the retina of a healthy sixty-year-old
is one-third that of a twenty-year-old.”
And then splotchy skin begins to appear.
“Inside skin cells, the
mechanisms that clear out waste products slowly break down and the residue
coalesces into a clot of gooey yellow-brown pigment known as lipofuscin. These are the age spots we see in skin. When lipofuscin accumulates in sweat glands,
the sweat glands cannot function, which helps explain why we become so
susceptible to heat stroke and heat exhaustion in old age.”
Most high-performance athletes will have retired by the
age of forty.
“Around age forty, one begins to
lose muscle mass and power. By age
eighty, one has lost between a quarter and a half of one’s muscle weight.”
Cherish and care for your teeth—they may not be with you
for the entire journey.
“The hardest substance in the
human body is the white enamel of the teeth.
With age, it nonetheless wears away, allowing the softer, darker layers
underneath to show through. Meanwhile,
the blood supply to the pulp and the roots of the teeth atrophies, and the flow
of saliva diminishes; the gums tend to become inflamed and pull away from the
teeth exposing the base, making them unstable and elongating their appearance,
especially the lower ones.”
Care can help maintain the health of our teeth, but the
afflictions of aging such as arthritis and tremors make the scrupulous brushing
and flossing difficult.
“In the course of a normal
lifetime, the muscles of the jaw lose about 40 percent of their mass and the
bones of the mandible lose about 20 percent, becoming porous and weak. The ability to chew declines, and people
shift to softer foods, which are generally higher in fermentable carbohydrates
and more likely to cause cavities. By
the age of sixty, people in an industrialized country like the United States
have lost, on average, a third of their teeth.
After eighty-five, almost 40 percent have no teeth at all.”
As we lose calcium from the places it is needed, it seems
to migrate to places where it is harmful.
“Even as our bones and teeth
soften, the rest of our body hardens.
Blood vessels, joints, the muscle and valves of the heart, and even the
lungs pick up substantial deposits of calcium and turn stiff. Under a microscope, the vessels and soft
tissues display the same form of calcium that you find in bone. When you reach inside an elderly patient
during surgery, the aorta and other major vessels can feel crunchy under your
fingers. Research has found that loss of
bone density may be an even better predictor of death from atherosclerotic disease
than cholesterol levels. As we age, it’s
as if the calcium seeps out of our skeletons and into our tissues.”
We can affect the rate of these processes by exercising
in an attempt to maintain functionality, and eating a healthy diet, but the
processes cannot be stopped.
“Our functional lung capacity
decreases. Our bowels slow down. Our glands stop functioning. Even our brains shrink: at the age of thirty,
the brain is a three pound organ that barely fits inside the skull; by our
seventies, gray-matter loss leaves almost an inch of spare room. That’s why elderly people….are so much more
prone to cerebral bleeding after a blow to the head—the brain actually rattles
around inside. The earliest portions to
shrink are generally the frontal lobes, which govern judgment and planning, and
the hippocampus, where memory is organized….Processing speeds start decreasing
well before age forty….By age eighty-five, working memory and judgment are
sufficiently impaired that 40 percent of us have textbook dementia.”
The accumulated changes lead to some accommodations that
we must make. For example, aging causes
the shape of the spine to change resulting in your head being tipped
forward. If one attempts to swallow
while keeping their head looking straight ahead it is easy to choke on
food. The elderly tend to eat facing
downward.
The loss of muscle strength is one of several factors
that increase the risk of falling for the elderly.
“Each year, about 350,000
Americans fall and break a hip. Of
those, 40 percent end up in a nursing home, and 20 percent are never able to
walk again. The three primary risk
factors for falling are poor balance, taking more than four prescription
medications, and muscle weakness.
Elderly people without these risk factors, have a 12 percent chance of
falling in a year. Those with all three
risk factors have almost a 100 percent chance.”
People tend to assume that modern medical practices will
lead to better, healthier lives for all, including the elderly. If this were the case, one might expect
people to age more gracefully, avoiding some of the inevitable disabilities
until a more advanced age. This presumed
trend is referred to as “compression of morbidity.” Unfortunately, the opposite seems to be the
case. There are data that indicate the
disabilities associated with aging are presenting themselves earlier, not later.
Interesting results
have been obtained by Eileen M. Crimmins and Hiram Beltran-Sanchez in the paper Mortality and Morbidity Trends: Is There Compression of Morbidity? Their paper appeared in 2011. Consider this table from the paper.
These data are based on surveys taken in 1998 and
2006. Over the span of just eight years
people of all age groups are reporting greater incidences of what the authors refer
to as mobility functioning loss. Things
like being unable to climb stairs or get up and down without assistance are associated
with old age. People seem to be hitting
their senior years in worse shape than they were in the past. Other data are presented that indicate
increased incidences of non-infectious diseases. We, as a population are becoming less healthy,
not healthier. The authors provide this
summary.
“Mortality declines have slowed
down in the United States in recent years, especially for women. The prevalence
of disease has increased….Mobility functioning has deteriorated. Length of life
with disease and mobility functioning loss has increased between 1998 and 2008.”
We are living longer but getting sick, and falling apart,
earlier. This paradoxical result has led
some to conclude that we are not living longer; we are just dying more slowly.
Up to this point, we have developed a picture of
inexorable physical decline leading to extreme limitations on possible
lifestyles. The elderly have had to shed
many of the activities that once were the core of their existence. They also must face their ever nearing
mortality. One might expect this to
become a period of extreme despair. Surprisingly,
the opposite occurs. Psychologists who
study such things claim that satisfaction with life becomes greater as one
grows older, provided one manages to emerge from the despair and depression that
characterizes middle age. This finding
is discussed in an article in The
Economist: Age and happiness: The
The questions being asked seem to be concerning
psychological well-being, or satisfaction with life. These are not necessarily the same as
happiness, but definitely something moving in a positive direction. If one asks about feelings of depression as a
function of age the curve turns upside down with the peak being where the
valley had been. The aged who are
terminally ill are probably not being queried about their satisfaction with
life, but it seems that those who are well into the falling apart process are
dealing with it quite nicely. This U-bend
profile seems to be fundamental to humanity in general. It is replicated in most countries, although
the position of the valley will move around from one society to another.
A number of possible explanations for the U-bend
phenomenon exist and are discussed in the article. For our purposes here, it is important to
note that those who are well along in the falling-apart process have managed to
maintain a degree of satisfaction with their existence. They know that they could die at any time,
but still persist in having hopes and expectations. They are people who continue to lead a meaningful
existence. However, their nearness to
eventual mortality means that the medical community owes them considerations
that are different from those that would be appropriate to younger people.
Gawande argues that a thirty-year-old who acquires a life-threatening
illness has the potential for decades more of a healthy life if that illness
can be defeated. In that case, it makes
sense to try all options, no matter how painful or uncomfortable they might be
to win the battle.
But a similar illness detected in an eighty-year-old
provides a different set of considerations.
There are no decades of health to look forward to. Instead, trying to defeat the illness may
actually lead to a shortening of life, with death coming while hooked up to
machines in an intensive care ward and in a state where one is unable to
communicate with family or friends. The
patient might prefer to make the best of whatever is left of life and forego
any heroic medical adventures.
Gawande is irate because too many doctors do not
understand the importance of the perspective of the elderly patient and encourage
the pursuit of maintaining life, whatever the cost. That is what they are trained to do, but it
is also the easiest thing for them to do.
What they are least trained to do, and what they seem to find hardest to
do, is have an honest discussion with the patient of what a given treatment
might entail and what its potential benefit might be—to the patient.
Gawande offers his feelings about how medical
professionals should approach treatment of the elderly.
“Sometimes we can offer a cure,
sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions,
and the risks and sacrifices they entail, are justified only if they serve the
larger aims of a person’s life. When we
forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be
breathtaking.”
Everyone should read Gawande’s book. It has relevance to everyone, no matter the
age, and it contains much more than was presented here.
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