How Many of You Expect to Die?, Dr. Joanne Lynn asked:
The audience fell silent, laughed nervously and only then, looking one to the other, slowly raised their hands.“Would you prefer to be old when it happens?” she then asked.
This time the response was swift and sure, given the alternative.
Then Dr. Lynn, who describes herself as an “old person in training,” offered three options to the room. Who would choose cancer as the way to go? Just a few. Chronic heart failure, or emphysema? A few more.
“So all the rest of you are up for frailty and dementia?” Dr. Lynn asked.
On the screen above the dais, she showed graphs describing the three most common ways that old people die and the trajectory and duration of each scenario. Cancer deaths, which peak at age 65, usually come after many years of good health followed by a few weeks or months of steep decline, according to Dr. Lynn’s data. The 20 percent of Americans who die this way need excellent medical care during the long period of high functioning, she said, and then hospice support for both patient and family during the sprint to death.
Deaths from organ failure, generally heart or lung disease, peak among patients 10 years older, killing about one in four Americans around age 75 after a far bumpier course. These patients’ lives are punctuated by bouts of severe illness alternating with periods of relative stability. At some point rescue attempts fail, and then death is sudden. What these patients and families need, Dr. Lynn said, is consistent disease management to head off crises, aggressive intervention at the first hint of trouble and advance planning for how to manage the final emergency.
The third option, death following extended frailty and dementia, is everyone’s worst nightmare, an interminable and humiliating series of losses for the patient, and an exhausting and potentially bankrupting ordeal for the family. Approximately 40 percent of Americans, generally past age 85, follow this course, said Dr. Lynn, and the percentage will grow with improvements in prevention and treatment of cancer, heart disease and pulmonary disease.
These are the elderly who for years on end must depend on the care of loved ones, usually adult daughters, or the kindness of strangers, the aides who care for them at home or in nursing facilities. This was my mother’s fate, and she articulated it with mordant humor: The reward for living past age 85 and avoiding all the killer diseases, she said, is that you get to rot to death instead.
You can see why people don’t want to think about this.