5000 Weeks

5000 Weeks

    Sounds like a lot, doesn't it?  But that's somewhat closer to my mother's age, a far cry from the 23-week threshold that was mentioned on the last post (on preemies).  But just as with treating a newborn coming into this world, we in the U.S. spend a large amount of our healthcare dollars on the elderly in an effort to keep them from leaving this world (according to the government site, we spend nearly 5 times more on the elderly than we do on children for healthcare).  And despite what you read, the shift in population isn't there yet, the elderly (those over 65 years of age) representing just 13% of the U.S. population as of 2010 (the latest figures from the government's Medicare center).  Still, the amount spent is huge (figures are from 2014 and incorporate all age groups): Medicare = $618.7 billion; Medicaid (those who cannot afford to pay their hospital or medical bills and use government monies) = $495.8 billion; out of pocket health spending = $329.8 billion; hospital spending by patients = $971.8 billion; prescription spending by patients = $297.8 billion; doctor visits and other lab costs borne by consumers = $603.7 billion; paying for private health insurance by consumers = $991 billion.  Those of you in countries such as Canada or Europe or Scandinavia are likely shaking your heads and saying, "Whaaat?"  

    But new figures (enter the age of big data and algorithms crunching the numbers) show a different picture emerging.  By 2050, according to Evidence Base from the University of Southern California, a new study by Schaeffer Center researchers Etienne Gaudette, Bryan Tysinger, and Dana Goldman: ... predicts significant changes in the average future Medicare recipient.   By 2030, the typical elderly beneficiary will be female, slightly younger, more educated and more likely to have never smoked according to the study findings.  But, the average recipient will more likely be obese, disabled, and have more chronic conditions.  Another of their papers (this one on Medicare) reported: Medicare extends health insurance to approximately 14 percent of elderly who were uncovered before turning 65 and increases insurance generosity for a number of those who had insurance pre-65. As a consequence, it also affects their financial lives...the fraction of elderly with out-of-pocket medical costs that exceed income drops by almost half at age 65, from approximately 9 to 5 percent.  Our work also shows that Medicare has its largest effect on high health spenders: while it decreases median out-of-pocket medical spending by 15 percent, its effects on the top 5 percent of spenders is closer to 50 percent.  Medicare also substantially reduces subjective measures of financial stress such as reporting having medical bill problems, being contacted by collection agencies due to medical bills, and having to borrow and to use savings to pay for medical bills.  All these reports drop by approximately one third as individuals turn 65.  

    The Future Elderly Model, a huge collaboration* between the government, the Rand Corporation, the MacArthur Foundation and a number of respected universities such as Stanford and Harvard, crunches the numbers ever further.  Delayed aging is expected to result in better health despite an expected increase in chronic disease and obesity and a decrease in mobility; technological advances in both medicine and lifestyle, as well as anticipated shorter lifespans for those with serious health conditions are all factored in.  But here's one sobering discovery from their research: ...in 1975, 50-year-old Americans could expect to live slightly longer than most of their Western European counterparts.  By 2005, American life expectancy had fallen behind that of most Western European countries.  We find that this growing longevity gap is primarily due to real declines in the health of near-elderly Americans, relative to their Western European peers...In a series of studies, researchers used the FEM to estimate lifetime costs, life expectancy, disease, and disability for 70-year olds based on body mass; the consequences of obesity in younger cohorts for disability and mortality; and the value of treatments for obesity and diseases associated with obesity.  For example, results from the FEM indicate substantial social value of bariatric surgery for treated patients, with incremental social cost-effectiveness ratios typically under $10,000 per life-year saved.  On the other hand, pharmaceutical interventions against obesity yield much less social value with incremental social cost-effectiveness ratios around $50,000.


    But wait, I'm drifting here so back to the costs of healthcare and the elderly.  For many of us, what we decide now while we are healthy ("I don't want to live like that...just let me die") could all change once we are the ones who are confined to a hospital bed with tubes and machines beeping steadily.   What happened?  One moment we were active and looking to tomorrow as yet another ordinary day and the next (car accident, heart attack, robbery gone wrong, a slip on a sidewalk) we are possibly clinging to life.  At that point, our feelings of wanting to live may prove substantially different from now.  Just one more day, one more month, one more year.  The late Dr. Kalanithi asked this as a neurosurgeon doing brain surgery, an operation that could substantially change the patient's life upon awakening. In his book (When Breath Becomes Air) he asks: ...the question is not simply whether to live or die but what kind of life is worth living.  Would you trade your ability --or your mother's-- to talk for a few extra months of mute life?  Your right hand's function to stop seizures?  How much neurologic suffering would you let your child endure before saying that death is preferable?...What makes life meaningful enough to go on living?   And from the other end, when he sees the families standing nearby, he reflects that they: ...do not usually recognize the full significance, either.  They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them.  I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery--or, sometimes more likely, no return at all of the person they remember.  In these moments, acted not, as I most often did, as death's enemy, but as its ambassador.  I had to help those families understand that the person they knew --the full, vital independent human-- now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle.

    Luckily, my mother has already made many of these decisions.  No feeding tubes, no extra life-prolonging features (CPR at her age would like do more damage and cause more long-term pain than what would be offset by her recovery back to life) and yet, as I think I would be, she is puzzled by what is happening.  She realizes that age is now well upon her, that her body is shrinking while other parts are swelling (as her circulation diminishes, fluids and such tend to accumulate...bump an arm and a bruise appears, water builds in the legs and hands turn numb)...what is going on, she wonders?  But yet...she is there.  In that respect, I am fortunate for I can still chat with her (often, several times over the same conversation).  Her focus is now singular (multi-tasking is out), her worries all shrunken to a few small things...how she looks (where's my makeup, when's my hair appointment, that blouse is old...that sort of thing), or can she take care of herself in hygiene and, on the less-rare occasion, accepting those times when she needs help.  She is still feisty, still eating heartily and still 80% of the mother I knew...in her, I am watching myself.


    It is my hope that when the time comes, I can be as objective as Dr. Kalanithi, morally thankful for the time and yet preventing myself from my wishes overriding my mother's.  Many others are facing much more difficult times, times that bring in issues such as mental and physical limitations, time and financial limitations, work and exhaustion limitations, caring for others (your children or yourself) limitations.  To say that deciding to save a premature baby or to prolong the life of a loved one is limited to a set of data is to minimize and de-humanize the internal struggle that differs with each of us.  It is a personal decision, two lives, each deciding, two roads often converging and equally often, diverting.  But it is personal.  It is life.

    One set of words come from Dr. Kalanthini's book, words from the Bible, Ezekiel 37:1-3, King James translation:  The hand of the Lord was upon me, and carried me out in the spirit of the Lord, and set me down in the midst of the valley which was full of bones, And caused me to pass by them round about: and behold, there were very many in the open valley; and lo, they were very dry.  And he said unto me, Son of man, can these bones live?







*About the Future Elderly Model, from their site: The Future Elderly Model (FEM) is an economic-demographic microsimulation developed over the last decade by researchers with funding from the Centers for Medicare and Medicaid Services, the National Institute on Aging, the Department of Labor, and the MacArthur Foundation.  Its development is led by the USC Roybal Center for Health Policy Simulation, with collaborators from Harvard University, Stanford University, RAND Corporation, University of Michigan, and University of Pennsylvania...The Center has produced 55 peer-reviewed manuscripts.