“My mother died earlier this year. It came as a complete surprise. She was in great shape. I mean, she was 88, but she was so healthy.”
I am sitting across the white exam room from my patient. She is sitting in a black plastic medical chair, her leather purse at her feet, with manicured nails. Her fingers nervously tuck away a not-so-loose lock of short dyed blonde hair. She is in her 60s, and like her mom, quite healthy. The difference, which is all the difference, is that her mom was 88.
The irony of this comment distracts me every time because the surviving family member is genuinely bewildered. Here’s the truth: no one at 88 is “in great shape.” They are all on borrowed time. Every extra year and survived illness is the exception not the rule; a gift, not an expectation.
Humans have an undefined level of resilience that doctors refer to as “reserve.” When a young person gets pneumonia, for example, they can be quite sick, but still able to recover at home with oral antibiotics and bounce back quite quickly.
Conversely, when an older person gets pneumonia, they are in a much more precarious state to begin with so they tend to get much more physically ill. They often require hospitalization, intravenous antibiotics, and even oxygen support. *If* they recover, they do not return to their baseline, either. Rather, they return to a level that is less than before. Sometimes, it is 90% of where they were physically, but sometimes it is only 50% and they may require a nursing home to strive to get back to 70% of their prior physical health.
And let’s return to that *if.* Oftentimes, that older person becomes sick, very quickly becomes much sicker, and then declines over a few days to their death. The older person has much less “reserve” than the younger person. It’s the difference being a puddle in the middle of a humid jungle compared to a puddle in the dry desert. The puddle in the desert is at much higher risk of drying out than the one in the jungle, just as the older person is at much higher risk of severe illness and poor recovery than the young person.
So why does an older person’s death come as a surprise? It’s because we don’t talk about death much in our culture. As doctors, we often avoid the conversation with our older patients that says, “you’re less healthy than you used to be. You’re not as tough. You’re more likely to have a bad outcome from a disease that decades ago you would have recovered.” That conversation seems cruel in our culture and is not likely to be well received. Nonetheless, the appropriate time to discuss this would be during an advance directive conversation and ideally prior to a severe illness. Certainly, it’s important to discuss after an older patient has been hospitalized.
If you’re sitting here thinking, but my mom is in great shape, it’s true. She likely is, for her age. That’s why it is so important to discuss an advance directive with her. She is used to a high quality of life with physical independence. It’s important to know what kind of minimum quality of life is acceptable – her “Litmus Test”– so that you can be guided by this northern star if she gets sick. You want her to recover to a quality of life with which she is comfortable and happy.