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Being Mortal: Medicine and What Matters in the End - Atul Gawande book


TomBAvoider
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I was just given this book, and though skeptical, I must admit, it's pretty good.

 

https://www.independent.co.uk/arts-entertainment/books/reviews/being-mortal-by-atul-gawande-book-review-a-manifesto-to-help-the-aged-9814287.html

 

What I liked about the book was the abundant case descriptions of actual people aging and what went wrong blow by blow, including a fascinating case of a doctor who specialized in geriatrics and practiced for decades and his own journey into decline in his 80's and 90's. A lot of medical info too, regarding risk factors and so on. What I also appreciated a great deal, was the focus on quality of life in old age and independent living. Once you are no longer able to care for yourself, QOL declines steeply - and the book focuses on what can be done to substantially prolong the time when you are able to live independently and you can postpone being institutionalized.

 

There is a lot of discussion on this board (and on the list, historically), of how to prolong life, but little focus on practical strategies of how to manage life in extreme old age and the challanges of possibly not having the financial or personnel resources to make very old age a life worth living. Remember, you can't always count on family - even if you have children, there are many people sadly abandoned by their kids. And what if - like my wife and I - you have no kids? You must make sure that you are not helplessly isolated and lacking in resources - this is no minor consideration and I believe you must prepare thoroughly. You will decline, both mentally and physically. Are you ready to cope with that? What are your strategies?

 

Meanwhile, you can't always count even on medical professionals - the practice of geriatrics is in extremely steep decline. These days almost no MD chooses to specialize in or practice gerontology. Gerontology departments are closing in medical schools and universities all over the world. Teaching of gerontology is collapsing across the board. The crisis is getting acute. Who is going to take up the slack? Nurses in long term care and regular MDs who will treat your medical problems in isolation like they're used to with regular patients.

 

You must therefore prepare. I would like to think of myself as a "prepper" - not like the usual ones, who build bunkers in their back yard preparing for nuclear war or a post-civilization collapse with roaming hoards of Mad Max gangs. But a prepper who has carefully laid plans for when my decline makes me vulnerable across multiple axis of not just health, but social and economic attack. Make no mistake - the elderly are a targetted demographic for both criminals and legal means of skinning. Most here are in their middles - early, mid or late, so you may feel nothing and feel invincible. But I can see across to the horizon, and a storm is brewing. Build your shelter now, while you still have the strength and resources, because when the whirlwind strikes, there will be no reprieve until death itself. (This also applies to the old timers - Gordo, are you doing all you can? Dean? Others may feel too young to care, Khurram, MR etc.)

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Tom,

 

 Build your shelter now, while you still have the strength and resources, because when the whirlwind strikes, there will be no reprieve until death itself. (This also applies to the old timers - Gordo, are you doing all you can? Dean? Others may feel too young to care, Khurram, MR etc.)

 

All very good points. Coincidentally, my wife and I just met with our financial adviser and talked to him about long-term care insurance. My wife is particularly concerned because several of her family have suffered from Alzheimer's and so she is worried for herself and knows how expensive long-term care can be. He's going to get us quotes for the costs and benefits of signing up soon (e.g. Around 55) vs waiting until 60 or 65, as well as all the various options (different levels of monthly payout, duration of coverage, inflation protection etc).

 

Have you (Tom) or any other "old-timers" looked into or signed up for long-term care insurance?

 

--Dean

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Amusingly enough, Dean, I was just looking into long-term care insurance. Our situation (my wife and I) has some additional complicating wrinkles, in that we have family in Europe and what with dual citizenships, we also have to take into account options available to us over there (f.ex. Sweden has a very generous healthcare system). Before jumping into anything, we want to gather all the information we possibly can, so that we can make the best possible choices - we are rather active and like to travel, so we're not heck-bent on living our last years in any one particular place, as we feel at home whereever we are.

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This topic has actually been on my mind a lot lately (but am I really an "old-timer"? ;) 

 

My wife's grandmother (yes, we are young enough to still have a living one of those) had been living fine on her own up until just last month.  She is 94 years old, has a terrible (for an old person) 2 story home with kitchen downstairs and the only bathroom/bedroom upstairs, but she was handling that just fine.  However she fell recently, and couldn't get up, eventually the police broke down the door and found her on the floor, where she had been lying long enough that clots formed and eventually clogged up her lungs.  We all thought she was going to die in the hospital, her sensors were alarming almost continuously, she stopped eating (I've read this is actually common for the elderly in distress) they were talking hospice, she could barely whisper, had trouble breathing and mostly just slept, she was in the hospital for weeks, then all of a sudden she started recovering very nicely, regained her strength, and is now walking on her own with a walker.  But no one in the family really knows what to do next, she is still in rehab - she should move in with one of her kids, but neither of them are willing, which means either she moves in with a grandkid or goes to a nursing home, or gets some serious home care. 

 

I am the one who has looked into the most options.  You can find quality full time home care from an independent provider, I was able to find someone just through craigslist who had excellent experience, personality, and references - at a negotiable cost of about $100/day. This person would essentially do everything for you (food shopping, meal prep, all house cleaning, help with bathing and going to the bathroom, giving meds, etc). 

 

Then there are these new retirement communities - they have been building these places like crazy in my area, a serious boom - I guess that's good for seniors, because the competition should bring costs down.  Some of these places really impressed me, I visited several of them.  The nice new ones are like living permanently on a cruise ship. Every single day is packed with planned activities from morning to night, they have theaters, classes, field trips, executive chefs that will prepare anything for you at any time at no extra cost, some have multiple restaurants, pools, live entertainment all included.  I was about ready to check myself in! ;)  The cost for these places runs anywhere from $3,000-$4,000 month but costs are extra if you need serious extra care (like someone to bath you or wheel you around everywhere you want to go).  This place:

https://www.shannondell.com/

Required a refundable deposit of $265,000 then $2,000/month (and its so popular there is a long waiting list just to get in).

 

Not sure long term care insurance is worth much, from what I've heard the policies used to be much more generous, then the insurers got burned, and now they are much more limited.  Statistically speaking you are supposedly unlikely to need long term care, although I suspect for people who aren't likely to die from a heart attack (hopefully that's most of us) we may actually be MOST likely to need it eventually, but if you don't need it until your 90's or later, I wonder if the policy would ever be worth it vs. "self insure"?

 

At any rate, if the cost is around $50k a year which essentially covers 100% of your needs, that basically means as long as you have after tax income of $50k you may be just fine even without insurance.  I should also point out that the cost does not double for a couple (husband and wife) if they go in together it seems to only bump the price up by 25% at most places.

 

But "Grandma" can't afford any of these options, which still leads to moving in with family, going to some "dive" of a nursing home, or trying to get by with some very limited part time help and in-home care (plus installing some stair lift device or moving to a more suitable home).  Home elevators will probably be a big growth industry:

home-elevators.jpg

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Thanks, Gordo, and I apologize for calling you an "old timer", but in my defence, I meant that as much for being a long time member around here, so perhaps no direct reflection on age :)

 

Anyhow, the Gawanda book goes into great detail about various housing and retirement options and communities, so what you are seeing is part of what he describes in the book - with baby boomers on the way out, such options should proliferate like crazy, so by the time we're of age, there should be more options. Interestingly, I have a friend who is one of the biggest film producers in Europe, and on a recent trip, I toured a house he just build for himself and his wife - and the #1 consideration for him was it being "old friendly". The architects worked very closely with a gerontology specialist who has vast experience in living spaces for old people. It was amazing. Every room was carefully designed, the bathroom, the kitchen and so on. As happens the guy himself is a health fanatic, so I joked that at best he may have a couple of months of use of all those features as I expect him to go on strong and then die very quickly without long periods of time in f.ex. a wheelchair. However, his wife is in poor shape, so that may have some marginal utility. But yes, people rarely think of how their house is designed and how it'll be to live in it once they reach the age of disability, so retrofitting could be a big industry going forward what with the boomers retiring.

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  • 5 weeks later...

An interesting topic. I'll be 79 on June 18, and I'm still teaching full time at the University of Rochester. My wife is 64, and is a relatively "healthy eater", but not practicing CR. She would like to retire. I have no such desire. UR has very good medical insurance; and teaching math is easy. I do vigorous exercise almost every day.

I have a considerable sum in my 403b -- when my wife retires, I point out that I can withdraw the amount she would have earned easily from my 403b, and still have almost a limitless supply.

Of course, eventually I'll either collapse rapidly, or might go into a morbid decline.

I have a feeling it's the former.

But, eventually the grim reaper will get to all of us.

 

-- Saul

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But, eventually the grim reaper will get to all of us.

 

I have a friend who sincerely does not believe this. He is 62. He laughs when I tell him that death is inevitable, and calls me superstitious. He does not believe it will happen to him - medical science will make enough progress in the next 30 years that it'll save him in the nick of time. He comes from a very long lived family - centenarians - and is confident he can hang on long enough for science to solve the problem. That's why he's very, very confident that he won't die - as long as he avoid accidents, which is why he is generally very careful about taking risks. But if you're 79, I can see why you might be pessimistic. 

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Well, let your friend dream on. He is probably happier believing that he'll live forever -- of course that's nonsense. Even the universe probably has a finite"lifespan".

As a child of about 10, I thought about this conundrum -- that I would eventually die. Being 79 has nothing to do with it; IMO it's best to face the reality of our mortality. But there's nothing wrong in believing in immortality, if that makes you happier.

-- Saul

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Also, I'm not yet 79! That will happen in one week (next Monday). I'll be at my favorite vacation spot, the Kripalu Center for Yoga and Health, in the Berkshires in Western Massachusetts. Their included buffet meals include the most CR friendly dishes that I've seen anywhere (including at some CR Society meetings). Most of it is vegan.

And their two daily yoga sessions are great. There's also presentations, often including interesting topics from Asian philosophies.

-- Saul

Edited by Saul
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I don't think it's irrational to believe that within 40 years there'll be some medical progress where we can reverse some or many aspects of aging to live longer. And then the whole idea of longevity escape velocity would apply. 

Immortality sounds a bit silly, even to most people involved in life extension, but no one can say for definite that we won't postpone death for such a long time, that it's pointless worrying about death from aging anymore.

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Dream on.

 

You'd be surprised how many people are "dreaming on" this way. Whole communities are built around Kurzweil's "escape velocity" and "singularity" concepts of science beating aging. A good chunk of Silicon Valley has similar dreams. I mean, I wouldn't be shocked if some folks reading the CRSociety boards don't similarly "dream on". To me it seems like it obviously is way way way ahead of its time - I don't believe for a second that we'll beat aging as a death cause within the next 100 years, but I wouldn't bet that humanity won't be able to do so in say, 200 years. Who knows. I'm sure it won't happen within my lifetime (another 40-50 years), but there is a very small chance it might happen a few decades after - the pace of scientific progress is inherently unpredictable, and there are no laws of physics/chemistry/biology which make the prospect of beating aging impossible (unlike, say, a perpetual motion machine). So those who "dream on" and are quite young - 20's, 30's at the outmost - are not 100% bonkers, just extreme optimists.

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But even a prediction of 100-200 years is kind of baseless, right? It's just an opinion.

 

There are good reasons to be optimistic, especially considering that the tools available right now are far better than even ones from 10 years ago.

 

If things were done the old way then I'd say there wasn't a good chance and I'd be as pessimistic as you.

 

But we have fast genome sequencing and scientists are better able to edit genes in a much faster way using technology like CRISPR.  We can also use artificial intelligence (deep learning and machine learning) to help guide research and maybe even come up with ways to treat disease. There is stem cell advances happening all the time and clinical studies are showing signs of success (same for gene therapy in reversing or curing diseases).

 

There's a lot more than that going on, but research is going much faster than it did before. I just don't believe that within 40 years there will be no progress in medicine and no extension of life. It's not as if the technologies have to be perfect, they just need to do a good enough job to reverse some of the damage to extend life by idk, 15 or 30 years or so, and the technology can improve in that time frame. I'm sure you're already familiar with longevity escape velocity anyway. It's a pretty simple concept that pretty much everyone who doesn't read up on this stuff completely misses or fails to understand.

 

I think CR will get me to 2100 or pretty close (I'd be 116).

 

I wouldn't say I was extremely optimistic.  :lol: I'll keep eating my 1500 k/cal a day and dream on   :rolleyes:

Edited by Matt
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There are good reasons to be optimistic, especially considering that the tools available right now are far better than even ones from 10 years ago.

 

Well yes, but I am guided by a different experience - having lived long enough to note this phenomenon when it comes to biology/medicine (and even some purely physics/engineering) breakthroughs - namely, progress on the deep problems (cancer, aging, controlled fusion power, true AI) is dilatory in nature; i.e. every breakthrough seems to lead to initial optimism until in due time it proves that the problem is more complex and the ultimate solution is delayed yet again. And again. And again. When DNA (and then RNA) was characterized structurally in the 50's-60's, there was huge optimism about imminent breakthroughs, cancer cure etc. But nada. War on cancer in the 70. Then nada. Then there was a giant burst of optimism with the bonanza rise of the biotech industry, curing cancer and a slew of diseases. More delay and more complexity. Then in the 90's there was massive hype and hope about stem cell research and cures for everything from Parkinson's to a hangnail, California and other states invested hundreds of millions. Nada. Then the human genome was sequenced (2000) and huge optimism about personalized medicine, cure of cancer and a slew of medical conditions. Here we are almost 20 years later, and more complexity and even the richest among humans with access to the best continue to die of cancer in huge numbers (see: Steve Jobs). Today it's CRISPR and affordable personal genetic testing and I predict similar ratio of Hype (or Hope) to eventual Reality H/R always a disappointing number. Already personal genomic testing is falling apart as "the great white hope" - see the recent thread I started about the complexity of gene/environment/lifestyle interactions which render early hope/hype hopelessly unrealistic... it's dying. Soon enough issues with CRISPR will turn up, as they did back in the day with stem cells and so on. Tomorrow no doubt there'll be something new to get excited - "but surely this time" - in cartoon terms, it's the football Lucy always removes, but Charlie never loses hope that this time will be different. 

 

For that matter problems which are much simpler - fusion power - are also frustratingly forever "10 years away" from being solved, and have been since the 1940's. That's a lot of corners we were supposed to turn.

 

Posts on a message board are not a good format for discussing issues in depth, but there are good solid reasons why such simplistic optimism is misguided. There are deep, deep reasons why progress on such issues is slow - or rather, there's always progress, but the ultimate solution seems always delayed. Think of it in terms of complexity - there are in mathematics problems which are classified as inherently unsolvable... it gets a bit far into the weeds, but if you google around you'll see (this is NOT about problems which are currently unsolved - but about problems that are unsolvable in principle). Similarly when complexity gets up to a certain point - which is reached remarkably quickly - there are simply not enough atoms in the universe and limitations of the speed of light which make the number of calculations necessary to solve an equation, simply not feasible. Now look at that paper I created a thread about - you have thousands of genes interacting in incredibly complex ways, and then throw in countless environmental and lifestyle variables, and you're sitting on possibly unsolvable problems. Think of it this way - when you employ passwords of certain length and complexity, they can never be solved given how long the universe will last, how fast the speed of light is and number of atoms in the universe. Note, you can't crack such passwords, and merely invoking incantations like "AI assisted, deep learning, machine learning" is of no help (akin to invoking hopeful magical phrases). It's impossible, even theoretically. And you reach such numbers - where the password/problem - becomes unsolvable very, very quickly - you don't need a password with hundreds of different characters and hundreds in length - the game is over by the time you reach mere dozens. Now, what if some of these biological problems are of at least the same complexity? For example, number of genes and possible interactions between themselves, let alone throwing in more endless variables from the environment and lifestyle? I bet you'll reach unsolvable levels very, very, very fast - and no amount of AI or any other theoretically possible tech will help. It's like the Uncertainty Principle - throwing more resources at it won't make it suddenly a Certainty Principle, it's a hard limit.

 

All I'm saying is that there are good reasons to think that as complexity escalates, certain class of deep problems will continue to be hard to solve. You could of course run permutations (as in brute force calculations) in f.ex. password cracking, and by chance might get simply lucky to hit upon the right one, but it's still PURE LUCK at that point, not in any way a reasonable prediction. And that's how you can try to calculate what the odds of such luck are given the number of variables, and come to some rough estimate like "we might get lucky in 200 years odds are HIGHER, but probably not in the next 6 months, or 20 years or 80 years odds are much LOWER".

 

Bottom line, I do believe you have to simply be an optimist to say "oh yeah, we'll get lucky" - and depending on the odds, perhaps an insane optimist - when it comes to a certain class of "hard" problems, like the problem of aging/death. There will always be "progress", but the solution will always be delayed. The more we learn, the more we'll realize how little we know and how much MORE complicated it all is. But I do like your attitude :)

Edited by TomBAvoider
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IMO, there's little doubt that medical and biological developments will lengthen our healthspan, and possibly lifespan. And I'd be surprised if there weren't many people who (tried to) believe in their potential immortality. However, considering that most people in these Forums are probably of above average intelligence, I doubt that these "many" are anywhere near "most".

So, no, I wouldn't be surprised if many people in the Forums believed in their potential immortality.

 

"Hope springs eternal to the human breast; man is always to be blest".

 

-- Saul

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