Can we live past our time? We are collectively living deeper into the realm of old age. For the first time in history, the oldest-old (age 85 and over) and centenarians (age 100 and over) are the fastest growing segments in global population. Some people have referred to this period of time as the, “rise of the mass geriatric society.” The experience of these extra years, however, is highly variable. Living longer also means increased physical challenges and the potential for prolonged suffering. Sadly, living old may sometimes mean living too long.
Living Old and Healthy Longevity
How Long Can We Live in Good Health?
Living old was not kind to my parents. It’s a strange thing to say, but I suspect that both my mother and father, “live past their time.” Even though medical science kept them alive to age 90, their quality of life during their final years, especially for my mother, seemed wretched. The normal course of aging had conjured levels of frailty that imposed distressing levels of suffering.
“We’re on the threshold of the first-ever mass geriatric society,” says Dr. Leon Kass, chairman of the President’s Council on Bioethics from 2002 to 2005. “The bad news is that the price that many people are going to be paying for [an] extra decade of healthy longevity is up to another decade of anything but healthy longevity. … We’ve not yet begun to face up to what this means in human terms.”
– Dr. Leon Kass in Frontline: Living Old
Healthy longevity is is the intersection of long life and good health. HALE, or health-adjusted life expectancy, is a measurement used by the World Health Organization to calculate healthy life expectancy at birth (the absence of serious disease or illness). Their data showed that in 2015, the average age for healthy-life expectancy was 63.1 years.
With increasing numbers of people living past 85 and 100, increasing numbers of people will be living with some form of chronic disease or disability. For some, this means 20 to 40 years of life in a state of compromised health. As Leon Kass points out, “We’ve not yet begun to face up to what this means in human terms.”
Frontline: Living Old
The series FRONTLINE: Living Old explore the realm of the oldest-old and highlights courageous contributions from elderly people nearing death. These experiences are further elaborated through commentary from geriatric doctors, care-givers, and the children of elderly parents. The summary below highlights some of the key ideas in the program.
Living Old – Part 1: Our Aging Society
Dr. Leon Kass refers to this trend as the emergence of the first mass geriatric society in the history of humankind. The United Nations Population Division conducts research into global population trends. Trends in global population ageing is one of the themes studied. The “World Population Ageing 2015” report offers some important insight.
- “Between 2015 and 2030, the number of older persons — those aged 60 years or over — in the
world is projected to grow by 56 per cent, from 901 million to more than 1.4 billion.”
- “By 2030, older persons will outnumber children aged 0-9 years (1.4 billion vs. 1.3 billion); by 2050, there will be more people aged 60 or over than adolescents and youth aged 10-24 years (2.1 billion vs. 2.0 billion).”
- “The number of people at very advanced ages is increasing too: the global population aged 80 years or over is projected to grow from 125 million in 2015 to 202 million in 2030 and to 434 million
We know that the probability of contracting an age-related disease increases over time. Health care systems are designed to provide acute care, while the provision of chronic care needs is limited. There also seems to be a lack of geriatric doctors relative to the aging population. The University of Waterloo states that shortage of geriatricians in Canada creating perfect storm.
Living Old – Part 2: A Looming Crisis in Care?
“It has been the most difficult time in my life, because I’ve had guilt. I don’t think anyone wants their parent or a loved one to have to be in an institution.” (In Frontline: Living Old)
The second part of Living Old explores the challenges in providing effective home care for elderly parents. Depending upon the sophistication of the care required, the estimated cost of twenty-four home health care is $150,000/year. The “sandwich generation” find themselves in the difficult position of simultaneously providing care for their parents as well as their own family. Depression in the sandwich generation is not uncommon.
The family is the largest provider of home care for elderly parents. The period of home care can last several years. With home-based care strategies in place (also known as “aging in place“), my parents were able to live at home until approximately the final two years of their lives. It is estimated that elderly parents with three or more daughters have a 50% chance of not moving to a long-term care facility.
Caregiver burnout is a common problem for family members providing support, and especially for those in the sandwich generation. In essence, “burnout” occurs through physical, mental, and emotional exhaustion. Another possible feature of financial burnout, that is, caregiver providing financial support can have trouble making ends meet.
Living Old – Part 3: The Importance of Home, Independence, Family
“Nothing has prepared me for taking on the role of caring for my mother.” (Statement made by a daughter and nurse in Frontline: Living Old)
This is a striking insight. As a son providing care for my parents I often felt that my lack of knowledge about the healthcare system was a barrier to my effectiveness. In this case, even a trained nurse felt inadequate to the task. And the harsh reality is that we will always be inadequate to the task. Even though a caregiver is fulfilling one of the most valuable roles a human being can undertake, the caregiver encounters significant amounts of physical stress and emotional pain as well.
The loss of independence is one of the most devastating effects of living old. Age-related frailty eventually forced my parents to leave home and move into a long-term care facility. The loss of our ability to live at home is, for me, one of the most devastating consequences of advanced aging.
A number of insightful comments made in this segment:
- A 99 year old woman – “I’m not afraid (of death), I don’t want to live forever.”
- One participant in the program referred to the nursing home as “the waiting room,” or the place people go to wait for death.
- A deeply courageous comment – “I miss my friends. I miss my home. People say you can’t have everything, so I try to be happy.”
- A geriatric doctor expressing his own fears – “Giving up independence is the worst. It’s what everyone fears. It’s what I fear.”
- A refreshing comment – “A nursing home not always a downturn for people.”
In my own experience, I have found that there is no real sense of “home” in a long-term care facility. Nor is there any real attempt to provide a home-like environment. Some facilities feel as if they are a form medicalized human warehousing. Some elderly patients feel as if they are in living in a waiting room for death. While independence must inevitably change toward greater interdependence, sometimes our institutions for the aging seem to foster dependence and compliance in order to streamline operations.
And when we enter into a long-term care facility, we pass through one of the final thresholds of life.
Living Old – Part 4: Parents and Children: A “Good Death”
What is a “good death?”
A good death, I believe, means to live a long life in good health, experiencing dying as a brief and relatively painless withdrawal from life, and at the moment of death leaving the world peacefully while surrounded by loved ones. No matter how we approach it, dying is a form of suffering, and it seems to be the thought of dying slowly and painfully that frightens us even more than death itself.
“When you are young you want to live forever, when you are old you don’t want to live forever – that becomes a fear.”
For a person of advanced age, the thought of living a long time in their current condition is frightening. This resonates with the “struldbrugs” in the story of Gulliver’s Travels. Although the struldburgs were immortal, they also experienced aging. In other words, through the struldburgs, Jonathan Swift created a dark vision of immortality. Sometimes, the condition of living becomes intolerable.
Your heart wants to fix everything, even though your head says you can’t.
There is another poignant scene that shows an exchange between a husband and wife who now reside in a nursing home together. They had been married sixty years, and he now had Parkinson’s disease (the second most common neuro-degenerative disease) while she suffers from Alzheimer’s disease (a common form of dementia). Their journey started as a trip to the hospital, which resulted in a short-term stay in a nursing home. They never returned home again.
Living Old – Part 5: Deciding When Enough is Enough
We can delay death to some extent. Medical science has developed remarkable techniques to preserve life. However, there is also the question of whether or not the use of these techniques serve to extend the dying process beyond reasonable limits.
Some of these techniques require permission, either from the elderly patient or a power of attorney. Sometimes children are required to make decisions they would rather not have to make. I can recall the final conversation I had with my mother’s doctor, and the heart-wrenching decision to begin palliative care that would make her death immanent.
A living will, or advanced care directive, is a document that allows a person to die with dignity, and removes the burden of decision-making from the family. In this segment Dr. Leon Kass notes that it is impossible to describe all the scenarios in a document, and most decisions cannot be adequately expressed in writing. There are numerous questions to consider:
- When is the medical standard of care no longer in the best interest of the individual?
- How long should we use medical technology to intervene and delay death?
- When do medical tests become self-serving, and in fact be a cause of increased suffering?
- How can the children of elderly parents be helped to make a decision that no child ever wants to make?
- How do we get to the place we can experience acceptance in allowing a parent to die?
- How can we be fully present with a parent when medical interventions have stopped and they have entered into their final moments in this world?
Many of us have or will eventually witness the death of a parent. In my mother’s case, I sat beside her holding her hand as she took her last breath. My father died during the night alone. In both cases, I watched on helplessly as their bodies were placed into a body bag and taken away. I have never known such stillness and silence.
One of the most important life lessons I learned from this experience was the necessity of reclaiming my own death, that is, not leave the process of dying and circumstances of my death to chance.
Living Old – Part 6: The End of Life Decisions
“I tried to learn to walk, but it’s hard… So I don’t know what to look forward to. I don’t really look forward to anything. Old age is for the birds.” (Frontline: Living Old)
Does an individual have the right to end their life? End of life decisions are extraordinarily complex and difficult. Each person must make a decision about the use of physician-assisted suicide and euthanasia. As we explore the issues, we begin to clarify under what circumstance, at least for our self, living is no longer desirable.
Our fear of death is a significant weakness with respect to building a shared vision for aging in the age of longevity. And yet it is our fear of death that makes live feel valuable and precious. Life is something we don’t want to have to let go of, but inevitably that is exactly what we are required to do.
Living Old in Human Terms
Dr. William Koch states that, “society has not yet started to deal with living old in human terms.” Living old in human terms is about enjoying a certain quality of life, relationships, participation, and contribution in a supportive community environment. In other words, living old is as much about the quality of life as it is the length.
Medical science has developed the skill of rescuing the aged from dire circumstances. In my mother’s case, each time a medical crisis was averted, she seemed to lose something of herself in the process. And yet, all along the way, her urge to live was absolutely remarkable. Eventually, she became bed-ridden, lost a significant amount of weight, and became exceedingly frail.
In human terms, living old is an encounter with truth from which there is no escape.