I’ve been thinking about my own mortality a lot lately. That may sound morbid, and maybe it is, or maybe it’s just an result of what I’ve been going through lately or because I’ve been studying Stoicism, but in any case, it’s there.
Stoics say that it’s quite important to think about your mortality. If you acknowledge and embrace the fact that you are going to die, then you can live a better life because of it. It helps ground you on what is important in life.
So today I’m writing about our end of life. What does it look like? What are your odds of ending up in a nursing home? How do you make yours as good as possible?
Yes, I know this is not a light topic, but I think it’s an important one and one that nobody wants to talk about, except for Atul, that is. I promise to get to more uplifting posts after this one.
Let’s jump right in, shall we?
Being Mortal: Medicine and What Matters in the End by Atul Gawande
Early in the book, Atul makes the point that we all are living for independence. Tell somebody that they can’t live on their own anymore or that they can’t be trusted to walk by themselves anymore and watch their desire to live disappear. Nobody wants to have to depend on others to live.
Falling, the biggest threat of all
Falling is one of old age’s biggest risks. 350 thousand Americans fall and break a hip each year. Of those, 40% end up in a nursing home and 20% never walk again.
When it comes to falling there are 3 major risk factors:
- Poor balance
- Taking more than 4 prescriptions
- Muscle weakness
Without those risk factors, a senior has a 12% chance of falling. With those factors, it’s 100% likely they will fall in a year.
- Lift weights and stay strong for as long as you can. If you don’t lift weights now, start. When it comes to exercise, prioritize weights over cardio because if you can’t lift your bodyweight when you need, you’re going to have worse problems than a heart attack risk.
- Work that core! While lifting weights, make sure you’re fitting in core work. Get balance moves into the mix.
- If you take prescriptions, talk to your pharmacist (not your doctor) about interactions they may be having with each other and any side effects you need to be aware of.
Of all the med students that pile into classes each year, 97% of them take zero classes in geriatrics. It’s not a sexy profession, so why would students flock to it? But, that is our loss because Geriatric docs can have a huge impact on the longevity and quality of life.
The University of Minnesota did a study on 568 seniors over the age of 70 that were still independent but were at high risk of becoming disabled. For the half that got a Geriatric team, they were 25% less likely to become disabled, 50% less likely to become depressed, and 40% less likely to require home health services.
What do Geriatric docs do that is so impactful? They simplify meds, control arthritis, keep toenails trimmed, meals square, and they watch for signs of isolation and home safety concerns.
- If you happen to be lucky enough to find a Geriatric doctor, first, buy a lottery ticket, and, second, hang on to them for dear life.
- If you can’t find a Geriatric doctor, work with a Pharm-D to simplify your meds, take care of your feet (even if you have to pay for pedicures to do it), have your meals planned out and nutritionally solid, and stay social.
Our needs change as we age
Maslow’s hierarchy of needs, though a great model for anybody that feels like they have time, goes out the window when we feel that time is short.
Laura Carstensen, of Stanford University, found that when we feel our end is near:
- We let our larger circle of friends fall by the wayside as we focus on those closest to us.
- We start focusing on everyday pleasures that barely register when we are younger.
- We become less interested in achieving and accumulating and more interested in the rewards of just being.
- We are less ambitious, but more concerned with our legacy.
Studies have found that when folks are hit with a serious illness, they are concerned with:
- Avoiding suffering
- Strengthening relationships with family and friends
- Being mentally aware
- Not being a burden to others
- Achieving a sense their life is complete
- Make sure to give attention to those closest to you.
- Try to be more mindful of time going by. Study Stoicism. Practice meditation.
If you need a nursing home…
The average American spends a year or more in a nursing home during their life at 5 times the cost of independent living. Your chances of ending up in a nursing home is directly related to the number of kids you have. And, if you want more help as you age, you have better have had a daughter.
If you are in the market for a nursing home or an assisted living apartment, here’s what to look for:
- Smaller pods of people (no more than 16 people to a household)
- Private rooms
- Common living areas
- More independence and fewer safety precautions. More safety precautions means less independence, which is something we all want in this life. So don’t take that away. Instead, find ways that you can move freely without an aid hovering over you. Walker, wheelchair, whatever it takes to keep your independence.
If you’re offered hospice, take it.
Hospice is end-of-life care where the goal is to keep you comfortable as you live out your days. They address emotional, spiritual, and physical needs, and as somebody that has watched hospice nurses in action, I can tell you they are likely saints.
Accepting hospice can feel like you’re giving up because you’re not going to fight anymore and because of that you’ll die sooner. But the reality is that hospice can help you live longer, better, and with less trauma and pain.
If you use hospice, you’re about 1/2 as likely to end up in an emergency room compared to those that don’t and 2/3 less likely to end up in the ICU. You’re also likely to live 25% LONGER and have less suffering.
So, yes, you’re accepting the end, but that is not always a bad thing. You’re more likely to have a far less traumatic ending and live longer with hospice.
- If you find that your treatment will have low odds and likely mess up the rest of your life, go on hospice. As hard as it will be to “admit defeat”, it will be better for you and your family.
Questions to ask yourself if you are diagnosed with a terminal illness
In the book, Atul makes a thorough argument that doctors are not equipped to handle conflict (facing your mortality) with you. They’re not trained in grievance counseling and don’t want to talk about uncomfortable things with their patients. As a result, they are more likely to talk about treatment options and odds of success rather than whether or not you should do the treatment.
- 63% of doctors overestimate their patient’s survival time.
- 17% under estimate it.
- The average estimate is 530% too high.
- The better that the doctor knows a patient, the more likely they are to err.
The questions you need to ask your doctor to better understand your options are not just “can I live longer with treatment”, but also, “what will my life be like after treatment”.
To help make the decision to do treatment or not a lot clearer, answer these questions and share your answers with your doctor:
- What is your understanding of the situation and it’s potential outcomes?
- What are your fears?
- What are your hopes?
- What trade-offs are you willing to make and not willing to make?
Then, based on those answers, ask your doctor: What is the course of action that best serves me?
I love this quote from the book. It sums things up so nicely:
We are inflicting harm in patients rather than confronting mortality. If end-of-life discussions were an experimental drug, the FDA would approve it.
End-of-life discussions are not comfortable, but they are critical to having a better ending. Just talking about your wishes with your family can greatly reduce the turmoil of death and greatly reduce suffering for everybody involved. Not wanting to talk about it is natural, but it is also a sure way to make your family suffer more.
This isn’t just for the old or terminally ill. You should have an end-of-life plan laid out even if you’re young and healthy so that others that care for you know what you want to happen if things get dire. And, yes, your plan can change as you age.
Critical questions to ask for your end-of-life plan:
- Do you want to be resuscitated if your heart stops?
- Do you want aggressive treatments such as intubation and mechanical ventilation?
- Do you want antibiotics?
- Do you want tube or intravenous feeding if you can’t eat on your own?
I know this topic is not easy and I will likely lose some followers because of it, but it’s an important topic that you’re not going to find very easily in a Buzzfeed article, so I felt compelled to share it. I hope you found it helpful.
In my next post, I’m getting back to lighter topics. I’ll be looking at Gary John Bishop’s book, “Unfu*k yourself: Get out of your head and into your life”.