It's a well-known reality of health care economics that Americans spend a lot of money in the last year of life. I suppose that almost goes without saying, since serious illnesses and injuries that result in death are costly, at whatever age they occur. Being hit by a car and dying means you were hit by a car... in your last year of life. And that two weeks in ICU before you die is, obviously, expensive. But this truism is usually applied to Medicare dollars in the care of the elderly. This group often has protracted illnesses that require costly treatments, specialty care, hospitalizations and home-health, despite the fact that the improvements in outcome or length of life are often pretty limited.
When I was a young physician (younger... that's better) I sometimes jumped on the band-wagon and wondered why everyone wanted so much for so little gain. I was always surprised when elderly patients didn't want Do Not Resuscitate orders or other advanced directives to limit care. I would sit with other young physicians and we would ask each other, "What does he hope to gain?" Or of the family members, "Why don't they just accept the inevitable?"
That was then. I have taken care of the elderly for my entire career. And over the past year, especially, I have worked in some communities with especially high numbers of senior citizens. That, coupled with the fact that I see things differently since I'm, well, less young, has given me new insight. So let's re-frame the question. "Why don't the elderly want to simply give up and die without a fight?" To which the answer is, "They've lived long enough to know that every second is precious." Perhaps more importantly, they know that all of the people in their lives are precious.
I have watched elderly couples, 60s,70s, 80s, 90s, and the way that they hold hands. The way they brush the hair from one another's faces. I have heard them whisper "I'm here" in the emergency room and "I love you" in the ICU. I recently listened as an older patient called his wife on the phone from the hospital. "How are you? Well you sound fantastic! I'm fine." He encouraged her and comforted her, and wanted to simply hear her voice. They were anchors to one another in a treacherous, frightening world.
My son once reminded me of a saying, which I here paraphrase. "We die twice. Once when we breathe our last, and once when someone says our name for the last time." The elderly get this. They want to be with the people they love and to be remembered by them. And in particular, those with spouses hold on because that gray, infirm, frail woman or man whose hand they hold is the last repository of an absolute treasure trove of shared memories and stories. No one else knows the same subtle jokes, the same turns of phrase, the same looks that betray fear or joy. Nobody else remembers their trips to the beach or the way their children sounded when they splashed in the pool during vacation. Nobody else knows how to hold their hand just the right way. And no one else understands the importance of touching feet in bed under the sheets, or remembers their favorite restaurant now closed, or grasps the importance of that inexpensive ring worth more than a ten carat diamond.
Friends, children and grandchildren also hold such memories for the aged, or they hope to fill their descendants with those memories before they leave so that, for just a little longer, the stories will survive. They want their love, passion and experiences to remain, and not just in a box in a corner of an attic, that may or may not survive the purge when the house is sold.
The elderly want to fight death the same way we all do. Because life is incredible. And in fact, we should want them around. They have navigated many decades and many challenges. They have wisdom and they have perspective to spare and to share.
This Thanksgiving, if you want to really grasp the holiday, sit down with your older friends, uncles and aunts, grandparents and parents and ask them what they're thankful for and what they love. (And watch the way they love.) Because odds are, you'll learn something magnificent and hear some stories that deserve to be treasured.
Then, those "end of life" expenses might suddenly make more sense.