As a retired physician who has written a book about end-of-life issues for elderly patients, I have placed myself in an awkward position. According to most guidelines, at age 67, I am elderly. How will I approach the end of my life? Not only do my personal medical concerns career around in the echo chamber of my own mind, but I have the added challenge of trying to follow my own advice regarding end-of-life decision making. And, there are multiple examples of physicians who did not do that. Witness the example of Francis Warren, Harvard’s most famous surgeon of the 20th century, renowned for heroic cancer surgeries and prolonging life at all costs. He committed suicide with a firearm, at age 88, while dwindling from congestive heart failure. Or, consider Desirée Pardi, the hospice care physician with 11 years of breast cancer and eight years of practice, who refused to give up aggressive treatments with little likelihood of a cure, refused hospice care, and died after months of agony at age 41. Currently, I am 67 years old with high normal cholesterol, easily controlled high blood pressure, and the beaten down knees of an aging weekend warrior. So what do I do? Do I ignore my knees and exercise, knowing that I will just have to rest them for ever lengthier periods of time? Do I spare my knees by becoming a couch potato, thereby risking progressive cardiovascular deterioration? Do I obsess over the perfect level of exercise that will optimize my cardiovascular future but not hurry me toward knee replacements? Do I get knee replacements now so that I can be more daring, but in doing so risk a premature complication of surgery or a post-mature deterioration of the artificial joints? Or do I wait until I am truly disabled from progressive knee dysfunction at a more advanced age and thereby increase the risk of a surgical complication while having denied myself many weekend warrior experiences and memories? Which course of action will help me to live life more fully and which will cause me to age more quickly? Because unlike so many of my patients and friends, I know that I will age. I know that my comparatively good health is a privilege, not an entitlement. I know that disease can be managed but not controlled. I know that I am not immune or immortal. This is the type of question we should all ask regarding every aggressive intervention. Is there a course of action that will both prolong our life and improve its quality? Because seeking the former but not the latter is a zero-sum game. And, more challenging than my knees, how will I face any one of the several chronic illnesses (congestive heart failure, cancer, stroke, diabetes or dementia) that are likely to define the last years of my life? What if I survive a heart attack but suffer from heart failure? Will I accept or decline mechanical devices designed to prolong life while tethering me to a machine pending a possible heart transplant? What if I get cancer? Will I stop cancer treatments after the third or fourth round of failing chemotherapy as I have suggested other elders to consider? When speaking to groups of aging patients, I emphasize that while the unsympathetic statisticians at the Center for Disease Control cluster everyone over the age of 65 into a single demographic, “old age” is really the confluence of three factors; advancing numerical age, accelerating disease, and declining performance status (the ability to care for ourselves). Where these three lines intersect, then we are “old.” And how will I respond to being old with any one of the chronic diseases? Will I seek a palliative care physician and address issues only in terms of symptom control, recognizing there are no real cures for these chronic conditions? Will I recognize when treatments that are recommended to prolong my life will likely cause me to lose quality of life and diminish my performance status further? But what if I just dwindle? Do I fear debility as much as I claim? Or will I embrace dependency? When and where will I draw the line? I certainly do not plan to commit suicide but how will I otherwise hasten my death to limit my dependence? One of my worries is putting my family in a position where they cannot fulfill my wishes. In an effort to avoid prolonging a life of dependency and promoting a natural death, I have instructed my children that, when I am unable to care for myself, they should put a tray of food in front of me three times per day, but that they are not to put a spoon to my mouth or a straw to my lips. Can they arrange that? Can I tolerate that? Will the jurisdiction in which I live allow me to do that by defining hand feeding as a medical treatment? Another of my worries is hypocritically failing to follow my own advice. Did the hospice care physician who declined hospice care for herself tarnish her legacy or did she burnish it? Certainly, the rules regarding aggressive care are different at a young age. Death at a young age is a tragedy, and a miraculous cure at a young age appears to offer so much promise. Similar treatments at an advanced age offer much less tangible or quantifiable benefit. And, death at an advanced age is a loss, but it cannot be viewed as tragic. I am certain that I don’t have all the answers and I am concerned that I might not be able stay my own course. I am certain that I will not want to embrace the uncertainty of chronic illness, debility, and the dying process. But I am very certain that if I want to die at home, a preference expressed by 80 percent of elderly patients, then, at some point, I must say no to hospitalization and yes to palliative care. Source
