Monday, June 4, 2018

The Insanity Of Pursuing Longevity and Questionable End of Life Treatments, Endless "Wellness"

My brother Mike's death over the weekend highlighted again an issue we all must face: when or whether to finally call it quits and pull the plug - as it were- on any further treatments. In Mike's case his oncologist informed him-  soon after the diagnosis of stage IV liver cancer-  he could keep him alive an "extra few months" by use of radiation plus chemo, "but there would be side effects."  Mike wanted nothing of it, and said flatly 'No!' Further,  he delivered his DNR (do not resuscitate) form for when the final showdown arrived.

It did less than two weeks ago when he was barely able to eat more than a few spoonfuls of chicken broth.   He had no appetite at all and had already lost more than forty pounds in a few weeks.  He also said that if eating less meant speeding the end, as he'd heard or read, he'd certainly do it.  Saturday night was the end, as his daughter Ciara described his last minutes for us in a twenty minute phone call.  Apart from some last minute "flailing" - likely from not enough oxygen to his brain, he died peacefully.

Mike's death brought into focus my own battle with prostate cancer, with the most recent PSA at 2.7 (from a nadir of 2.0 last June) but the critical free PSA still sitting at 4.1%.  That low free value is not good news as it still translates to a 70 percent or more probability of the cancer still there.

After the results went to UCHealth in Aurora, the NP, Kristen, tried to talk me into getting another biopsy and also even a 2nd focal cryotherapy. I said no way, especially as I'd had three administrations of general anesthesia in the past two years which have left my memory with holes galore. See e.g.

 So I wanted no more invasive procedures that would necessitate general anesthesia. In fact, I didn't even want another invasive biopsy. The most I agreed to is another MRI if and when the PSA doubled from its nadir.  I also am disinclined to take any of the drugs, e.g. Lupron - that wreak havoc with cognitive capacity or cause depression. As I put it to her, what's the point of adding five or ten more years if they're going to be spent as a brain-addled vegetable?

This all brings to mind two recent books by different authors seeking to bring some semblance of sanity and rational discourse to the longevity, end of life debate, and keeping the wellness fetishism at bay. Indeed, in respect of this I've already pointed out the vast sums spent to keep patients alive, often against their will and dodging their DNR orders. (See the book, The Nurses, for more on this).

A provocative article by Josh Zepps, appearing at two years ago, points out the problem:

Medicare costs more than $500 million per annum, 30 percent of which is spent on the five percent of beneficiaries who die each year. One third of that is spent on the final month of life. The final month. I mean, you want to talk about priorities, let’s just take that one datum. More than $50 million each year spent on the final month of life.”

Zepps is correct about the magnitude of Medicare spending in the final months of life. But I believe that is the fault of the medical establishment and its specialist practitioners. This is based on not leveling with severely infirm elderly people regarding limits of additional treatments and their real costs vs. benefits.. Missing in most treatment discussions, for example, is any reference to quality of life .The focus is exclusively on quantity and that also often comes with huge medical costs. Missing "the talk" is it any wonder older patients tend to believe medical treatments can offer curative solutions rather than only palliative ones?

What can be done? Author Barbara Ehrenreich ('Natural Causes: An Epidemic Of Wellness, The Certainty Of Dying, And Killing Ourselves to Live Longer')  has a decidedly curmudgeon's point of view which is necessary amidst all the circulating happy talk,  medical codswallop.

Old age isn’t a battle,” Ehrenreich (also author of "Nickel And Dimed")  says, quoting the late Philip Roth, “old age is a massacre.” In the past few years, Ehrenreich has given up on screenings and scans, but that's not because she is lazy or suicidal. At 76, she just considers herself old enough to die.  Like me, she takes the attitude that no one of sanity, or any degree of rationality,  ought to be jumping onto the academic longevity bandwagon and aspiring to live to 160 or some similar nonsense.

 To her, aging is “an accumulation of disabilities”, which no amount of physical activity or rigorous self-denial can prevent. Hence, she takes all the self-help books aimed at her age group  with a grain of salt.  These include books spouting the usual balderdash:   “active aging”, “productive aging”, “anti-aging”, even “reverse-aging”, with a long life promised to anyone who makes an effort, regardless of factors such as genetics or poverty.  No surprise this unhealthy obsession with wellness fantasies is enriching these wannabe prophets and peddlers, e.g.  of schmaltz smoothies (for heightened wellness) to almost Trumpian wealth.  Hell, they're making more $$ than Trump with his Trump University con.

But - like me - if she has symptoms, she’ll have them investigated, at least in a first pass. But when a doctor tells her there could be an undetected problem of some kind and more tests are needed, she refuses to play along. What exactly makes her more percipient and wise to the wellness and extending health cons than most people?

In the 1960s, Ehrenreich had worked on immune cells as a Ph. D. student, specifically on those known as “macrophages”, and had come to think of them as friends – frontline defenders against microbial invaders.  Much more research instead  exposed them as traitors, including showing how they could become "biological double agents" for their role in cancer and autoimmune diseases. Hence, one of her basic "wellness" beliefs was shattered early and with it all the associated hokum delusionary twaddle. . If one's body can attack itself, then why bother trying to look after it? At least to any assiduous, extreme extent?

Overdiagnosis has become an epidemic. Bone density scans, dental x-rays, mammograms, colonoscopies, CT scans: she questions them all. Preventive medical care, in the US at least, has become a lucrative industry. Many doctors profit financially from the tests and procedures they recommend. And celebrity-driven campaigns for more screening increase the demand. People are being made sick in the pursuit of wellness.

Coming at the issue from a different direction is 37 year old Kate Bowler, author of Everything Happens For A Reason and Other Lies I've Loved. That title acknowledges that nothing at all - in terms of people's fates - need happen for a reason. One moment you may be walking peacefully down the street and the next a large scaffolding falls down and kills you. Yes, there may be lurking reasons in the fact the scaffolding was loosened and the law of gravity did the rest. But not that it would have struck you at the exact right time and place to kill you.  Same thing with a large tree falling on your house during a severe storm - crashing through the roof - and taking out one or more family members in their beds. Ditto with driving down a road when all of a sudden a large sinkhole opens up and you perish.

So, in many ways, as Prof. Bowler learned, life is a crap shot, such as after she learned she had Stage 4 colon cancer. And such as after my youngest brother learned he had stage 4 liver cancer. Bowler's colon cancer especially is something no 37 year old ought to remotely worry over, since screenings, colonoscopies usually aren't recommended until at least 45 or 50..   The greater irony is that Bowler had spent ten years - according to a WSJ review piece ('The False God Of Wellness', May 23, p. A13) studying the bogus American "prosperity" gospel, i.e. God "rewards the faithful with health and wealth" and lays diseases and calamities on the unbelievers and sinners.

Of course, this is rubbish. Any person of average intelligence scanning a given day's headlines in the papers can prove to himself this is errant nonsense to which only a fool would give credence. But in the land of perpetual optimists there are plenty of fools willing to believe it, as it gives them a sense of exception and some comfort. But as Prof. Bowler learned, it's all a thin veneer of fantasy.

Particularly objectionable for any cancer patient is to hear the constant martial refrains - often from well meaning people (including on survivor sites) - to "do battle" with the disease. Why?  If indeed Ehrenreich's theory is correct one's own immune system can "aid and abet"   the proliferation of the disease. So, one's own body become an ally of the cancer.   In Ms. Bowler's case, as the WSJ review article noted, she tired of hearing she had to "battle" the cancer and soon grasped this bollocks was merely an extension of the prosperity gospel of proto-Calvinist loons and buffoons. Amid the exhortations to be an "optimistic warrior" she realized she was tempted to partake in the prosperity bilge once more.  So she'd deserve a "full life" as wife and mother in exchange for her godly devotion, or in this case total optimistic faith in current medicine for a positive outcome..

Then dousing the fantasies she grasps (ibid.):

"One moment I was a regular person with regular problems, and the next I was someone with cancer."

Which is exactly how it is when you get the confirmed cancer diagnosis. There then follows listening to all the medical blabber of treatments and life extension possibilities from them, which gives the illusion of control. But, of course, as Ehrenreich notes, this can only be a total illusion if one's own immune system is at the core of the cancer and one's enemy.   As for Bowler, she describes control as a "drug that has us all hooked".  Indeed, and I admit falling for it too after the focal cryotherapy treatment last June and being assured the cancer was totally frozen out since it was "localized".

So I asked the UCHealth NP: Why has it seemed to come back? 'Well, it happens!'  Perhaps, but perhaps you guys never had it as much  under control as you assumed!

Even if we adhere to the most judicious diets and avoid all meats, alcohol, smokes etc. there is absolutely no assurance of continued wellness to the point of escaping all diseases such as cancer. And even if one manages to add years via saintly diets, they may not be years of life quality.  I can cite examples from my own extended family .Janice's cousin Desmond hardly ever touched animal fats over 80 years - no bacon, no burgers, no steaks  None of that. He also didn't smoke and drank only on rare (celebratory) occasions.. He was the full embodiment of the healthy, low BMI,  80 -year old male-  until he got Alzheimer's at the age of 83 and went downhill from there. Having to be kept in a special nursing facility with astounding expenses paid for by his family estate.  When we visited him for the last time he barely recognized us and had the vocabulary of a babbling two year old.

Would it not have been better in retrospect for Desmond to have gorged on animal fats, smokes etc. to spare him the indignity of his later lengthy decline as well as expenses?   You tell me.  Mike, by contrast, ate what he wanted ('Five Guys' burgers was a favorite place) and drank a  six pack of beer each night in his early days.  He also smoked like a trooper just like my other two now deceased brothers.  The commonality? All three died rather rapidly - no long stretches of decline with enormous medical bills or more treatments to stay alive.

According to a paper ( Death and Taxes: Why Longer Lives Cost  Money)  produced by the UK Institute of Economic Affairs:

"Despite the costs associated with the ageing population, it is sometimes claimed that people who are at risk of premature mortality due to lifestyle factors are a ‘drain on the taxpayer’. Smokers, drinkers and the obese, in particular, are blamed for rising costs to the general taxpayer.

These claims do not stand up against evidence. If one looks at the lifetime costs to all public services, it is clear that the ‘longevity-related’ costs of healthier people are considerably higher than the ‘lifestyle-related’ costs of less healthy people. Acute healthcare costs are usually higher, long-term healthcare costs are invariably higher, and welfare costs (eg. pensions) are vastly higher

The IEA paper goes on to elaborate:

:"In recent decades, healthier lifestyles and longer lifespans have been associated with a rise in the number of years spent in poor health. There has been a rise in the number of people suffering from chronic and non-fatal conditions which are often expensive to treat and manage. Medical science and healthier living do not eradicate the costs of disability and disease, they merely postpone them and pave the way for more expensive non-fatal conditions amongst very old people."

Whether one wishes to admit it or not, therefore, practicing healthy living or eating habits could merely be postponing massive, exploding medical costs until later as the IEA paper suggests.

Of course, no one - certainly not me - is advocating deliberate, dedicated consumption of high fatty foods, like the constant diet of Kentucky Fried Chicken that ultimately did in former child star Tommy Rettig  at the age of 54.  What we are saying is that one ought to be able to enjoy his food, even if those choices lean to burgers, the occasional steak and hot dogs, without being made to feel like a health spending criminal.  The reason is that it is actually the healthy eating zealots whose longer lives add the bulk of medical costs over time.  Maybe, indeed, we should strive more for a balanced quality of life - which includes eating what we wish up to a point - than emulating an abstemious monk.

And it is also plausible the wellness addicted zealots and those seeking ever more life extending treatments are driving our medical system into the dirt. Maybe the next time the wise-ass doc tells us: "Sorry, but you only have four months to live...unless you …."

We retort: "Thanks, doc, I am okay with that!"


Darrin Rychlak said...

My condolences to you and your family on the death of your brother. I have a brother too. I can only imagine the weight that went with confronting your brother's politics.

I'm holding out hope for your recovery. All I have are these:

I had a rough day, I asked the bartender to surprise me. He showed me a naked picture of my wife.

I told my psychiatrist that everyone hates me. He told me I was being ridiculous. I haven't met everyone yet.

I went to the doctor and said, "Doc, every morning when I wake up and look in the mirror, I throw up. What's wrong?" The doctor said, "I don't know, but your eyesight is perfect."

I went to the doctor because I swallowed a bottle of sleeping pills. He told me to have a few drinks and get some rest.

I told my dentist my teeth are going yellow. he told me to wear a brown tie.

My friend and I were pulled over by cop who asked, “Your Identification, NOW!” “I’m me, he’s him, and you’re you.”

If you're so pro-life, do me a favor: don't lock arms and block medical clinics. If you're so pro-life, lock arms and block cemeteries.

"At my age, if I don't drink, don't smoke, and eat only certain foods, what can I look forward to? From this point on, if I take excellent care of myself -- I'll get very sick and die."

That's a mix of Rodney Dangerfield and Bill Hicks.

I hope you feel better.

Copernicus said...

Thanks, Darrin! Terrific jokes - made my day!