Valar Morghulis

A few days ago there was a post up on The Pump Handle reporting on the Institute of Medicine's report, Dying in America, that critiques end of life care and suggests ways to improve it. The post linked to to an essay by Ezekiel Emanuel in The Atlantic on the topic of old age and death. The essay has the rather catchy title of "Why I Hope to Die at 75."

As it turns out, Emanuel doesn't really hope to die at 75. He's just decided that once he hits a certain point in his life, he's going to refuse all medical interventions other than palliative care. I get it. I've worked in nursing homes. I know that despite all the hype about "60 is the new 40" and ads showing geezers having a good time, aging in general sucks. You get older and it's inevitable that you're going to start falling apart. No one has the energy at 80 that they did at 50. You're more susceptible to injury. Your skin turns crepe-y, you bruise easier, it takes longer to heal. A fall that would have been nothing when you were in your 20s can put you in the hospital when you're in your 70s. Old people look frail for a reason -- they are frail. They break easy. Your bones start losing calcium; if you're unlucky you end up with osteoporosis and discover that all it takes is a sneeze and you've got broken ribs. Everyone says getting old beats the alternative, but some days you've got to wonder if that's really true.

And then there are the cognitive issues. One of the most depressing aspects of getting older is witnessing friends and acquaintances slip over the edge into Alzheimer's or other forms of dementia. Alzheimer's gets a lot of attention, but it's not the only way to slide into senility. When you're in your 30s or 40s and you hear people talk about "hardening of the arteries" you may think "that can't possibly be a real thing." Well, it is. It's what cholesterol build-up does; the fat narrows the arteries, makes them stiffer, reduces blood flow. Reduced blood flow means less oxygen to the brain. Less oxygen to the brain means you get more forgetful, less agile mentally. The next thing you know you're one of those dithering old people who can't remember where they left their coffee cup or wants to tell you the same lame jokes over and over and over. . .

Not all geezers go senile, of course. One of my favorite people of all time, the philosopher Marjorie Grene, was still going strong in her 90s. She could argue circles around scholars a third of her age. But Professor Grene was an exception just like my own mother (who is now 92 and still sharp as the proverbial tack) is an exception. Based on my personal family history, I don't think I'm at much of a risk of losing my ability to think before other stuff fails, but you never know. The fact no one I'm closely related to has ever shown signs of Alzheimer's doesn't mean I can't be the first in the family to go senile.

Anyway, the more I see of the prospect of getting to be my mother's age, the less attractive it becomes. It has to suck to outlive all your friends. It's like signing up for a tontine where the only pay-off is you get to attend everyone else's funerals. So I'm thinking along the same lines as Dr. Emanuel. Once I hit my sell by date (which I'd mentally set at 75 long before I read the essay), it's going to be palliative care only. No trying to delay the inevitable in a way that enriches pharmaceutical companies or helps a surgeon buy a new Mercedes. After all, in the end it doesn't really matter what you do -- you're still going to die.

Mortality

“Getting older isn’t easy for a lot of us. Neither is living; neither is dying. We struggle against the inevitable, and we all suffer because of it. We have to find another way to look at the whole process of being born, growing old, changing, and dying, some kind of perspective that might allow us to deal with what we perceive as big obstacles without having to be dragged through the drama.” – Ram Dass, Still Here (©2000)

Back when I was younger, I used to laugh at my aunt Ingrid's reactions to the news that someone had died. If the decedent was older than her, she'd sound relieved. Yep, he's dead, but, heck he was two years, five years, ten years or more older so it was no surprise the old dude had bought the farm. Yeah, he's dead, but he was ancient; I've got lots of time left. On the other hand, if the dead person was younger there'd be a kind of surprised, almost fearful response: but she was so young! This is such a shock! Even if the age difference wasn't great, like if she was 70 at the time and the decedent was only 69, she'd start looking worried. Time was obviously running out. 

Well, now I'm in my 60s reading obits and seeing life spans shorter than mine -- and I'm starting to have a similar reaction. Oh, shit. I'm not going to live forever after all. It's one thing to recognize that fact intellectually when you're in your 30s or 40s, but it feels a little different once you start wondering if you really should buy those green bananas. You start to hope you're one of the lucky bastards who drops dead unexpectedly and inspires bad jokes (hit the ball, drag Harry) and not one of the poor saps tethered to an oxygen bottle at the nursing home. 

Most of the time I don't think about it much, but this was one of those months where I wound up having conversations with my primary care physician about glucose levels, cholesterol, weight, and all the other things health care providers love to fret about. My blood glucose was a number that is now considered too high: they moved the goal posts a few years ago, so what was perfectly okay a decade ago is now Ohmigod-you-need-to-take-metformin. Ditto the cholesterol. The numbers haven't changed in years, they always hover right around just over the line, but every time my PCP sees them it's ohmigod-you-need-to-take-Lipitor. 

Why? Am I going to live longer? Well, no. Lots of studies have been done showing that if you're one of those just over the line people treating a condition that's borderline doesn't do a thing to increase your life span. Will it reduce risk of heart attacks or strokes? Ah. . . no. There isn't a statistically significant difference in outcomes for people whose cholesterol falls in that just over the line area. Well, what about quality of life? Are they going to make me more physically fit, help with aching joints, make it a little less scary scrambling up step ladders or easier to get up if for some reason I've decided to kneel on the floor? Nope, not at all. The only thing that helps with activities of daily life is exercise to retain mobility and flexibility.  

In fact, there are no good answers that justify taking drugs for a borderline condition, at least not for me. You go from knowing your total cholesterol is just over 200 to knowing it's just under while at the same time enjoying all the fun side effects, like gas that practically makes you jet propelled, diarrhea that has you wishing you owned stock in Kimberly-Clark, and giving up foods you like because they can interact in a bad way with the drugs. You haven't actually gained any years; it's just going to feel a lot longer because you're miserable. The line between "you're okay" and OMG is a fairly arbitrary one; it had to drawn somewhere, but that area on either side of it is a fairly fuzzy one. 

I can understand why physicians and other health care providers are reluctant to face the truth and admit that the stuff they're prescribing might not actually do much: they're dedicated to saving lives. It sucks that they can't offer their patients immortality (or even a comfortable old age). Handing a patient a prescription lets them feel like they've done something even if they really haven't. I don't know if I'll bother arguing with my PCP about this or not; I might just let her write the prescriptions and then not get them filled. She's talking about leaving L'Anse anyway (the winters are pushing her away). Odds are that a year from now I'll be dealing with someone new so the current PCP will never know how thoroughly I ignored her advice. 

I figure that at my current age, if all goes well, I've got a 50% chance of making it to 86. If the odds are only 50/50, I think I'd prefer to spend that time enjoying a decent qualify of life instead of shuffling pill bottles and wondering if I should invest in some Butterfly Body Liners. After all, nobody lives forever. 

"Lucky bastard"

From the National Park Service's Morning Report for today:

Rocky Mountain National Park (CO)Snowshoer Dies Of Heart Attack
A 74-year-old man from Fort Collins suffered a cardiac emergency while snowshoeing near Mills Lake on Tuesday, January 7th.

The man’s friends contacted park rangers by cell phone and began CPR, but were unable to revive him. He was pronounced dead around 1 p.m.

Mills Lake is almost three miles from the trailhead and close to 10,000 feet in elevation. Park staff, assisted by Larimer County Search and Rescue, recovered the man’s body and transferred it to the Larimer County Coroner’s Office.

As someone who has entered the Grumpy Old Men stage of life, i.e., the one where you start checking the obits in the morning to make sure you're not listed, I can't help but think that if there's such a thing as a good death, this guy experienced it -- out in the mountains, enjoying a hike with friends in a place he probably loved, and he keels over. Not much fun for his friends, true, but you can't win them all. 

If you thought the gift shops at Disneyland were bad

An elderly relative died this past Monday; the funeral was yesterday. In most ways, it was a pretty typical event. The decedent was quite old, she'd been in declining health for a number of years, and her demise was not unexpected. People were understandably sad, tears were shed, and life goes on. The funeral itself was what one would expect -- the minister talked about the wonderful characteristics of the decedent (a woman he had  met one time, and then only briefly) while those of us in the pews did our own mental editing/reality check. (If the dearly departed were even half as wonderful as eulogies always make the deceased sound, it would be a lot harder to let go.) The only surprising thing was that the church was not as full as I had thought it would be given how active the woman had been in the community in her younger days, but then I realized that the decedent had simply managed to outlive most of her contemporaries.

Visitation at the funeral home the night before held a few surprises, though. I've always been intrigued about customs and practices surrounding death, the various attitudes and rituals and their evolution over time. Americans have always struck me as being a tad squeamish about the subject. After all, the culture has abdicated personal responsibility by allowing professional funeral directors to take over what were once intimate family tasks: preparing the body for burial, for example, and digging the grave. For centuries, too, western culture has isolated the dead from the living: unlike some cultures where the bones of revered ancestors become part of the household (e.g., skulls up on the ceiling beams or bones buried in the floor), western European societies planted the dead in graveyards. That's changed a little with the advent of cremation -- during the 20th century it became acceptable, if not widely common, to have the cremains of a loved one residing in a tasteful urn on the credenza in the living room.

I've got to admire the funeral industry for managing to take that tasteful urn and move it to a whole new level. While sitting around sipping coffee at the funeral home, I realized I'd inadvertently wandered into the world's creepiest gift shop. The built-in bookcases and various other surfaces were full of display models of different items grieving families can purchase. You can now get individual urns:

Instead of the deceased's ashes residing in one large urn for all eternity, you can divide him or her among the family members. Personally, I find this a little creepy, but I know not everyone feels that way -- my older grandson was the recipient of such an urn after his other grandmother died a few years ago, and he seems quite happy to have it.

Individual urns not quite your thing? Or there are so many family members (and the decedent was a frail little thing who's not going to provide much ash to work with) that even the small urns are too large? How about some cremation jewelry? You can have ashes compressed into fake diamonds, or you can go for something a little less intense, like a heart you can wear as a necklace or on a charm bracelet:

What about the men, you ask? After all, guys aren't likely to want to wear a heart-shaped pendant no matter how much they loved their mother. Got them covered. Keychains, with a wide variety of designs to pick from:

I can see it now -- "I'll take the one with the gecko on it. Mom always loved those GEICO ads."

The options for stuff you can do with cremains don't stop with urns and jewelry, of course. You can take those ashes and have them made into stained glass. You can buy various pieces of innocuous looking household items that have compartments for cremains: desk lamps, for example. You can get urns that look like bookends (and can be used the same way) if you want to be subtle, or you can get urns that look like miniature caskets or sarcophagi if you want the urn to be a blatant piece of memento mori.

But what about families who don't opt for cremation? Aren't they kind of S.O.L. when it comes to death memorabilia? Not really. There are now these nifty little pieces of jewelry, which get sold by companies such as Thumbies:

You can have your loved one's fingerprints permanently embedded in a piece of (not cheap) jewelry that you can treasure forever. Holy crap. First they guilt you into the Cadillac casket, and then they swing into full up-sell mode by peddling tchotchkes to help guarantee that whatever estate the decedent had is thoroughly eviscerated. I'd love to hear the sales pitch for this stuff. What can they possibly say? Your mother's last wish was to be fingerprinted? She never had a chance to do one of those plaster-of-paris wall plaques in kindergarten; here's your opportunity to make it up to her?

Bottom line: prearrangements are looking better and better. Signing up with a burial society, making damn sure everyone knows the one and only thing I want is the absolute cheapest cremation done as quickly as possible, ashes in a milk carton or coffee can because they're going to get scattered, and no money whatsoever being spent in the world's creepiest gift shop.

[cross posted at I See Dead People]