Managing Older

photo from flickr

It's a reflection of how good the Australian health system is that most of its people are now the second longest living people on Earth. A baby born in Australia is expected to live an average of 81 years old, an average currently bested only by the Japanese. It's no wonder then that most of the patients we see at work are elderly - the mark of an aging population. Here it's quite commonplace to see active and healthy octogenarians and even nonagenarians, some just a couple of years shy of the century mark and a dinner with the Queen.

This is something that, as a doctor, is quite new to me, coming from a country where the life expectancy at birth is easily a decade below Australia's and most of our patients are lucky to get any medical treatment at all. Dealing with such an elderly population has been a learning experience in itself, but it has its own share of difficulties and heartbreaks.

Aging inevitably takes its toll on the human body, no matter how well one lives, so it's not surprising that most of our elderly patients have multiple medical problems. While there are also a number of elderly patients who have reached their grand old age with few serious co-morbidities, arthritic pain and reduced mobility is a common problem many share. A good number of them have been living in late-stages or even end-stages of many chronic illnesses for a number of years, the natural course of their diseases staved off by the good health and community support they are given by the system.

I had never seen many patients with dementia - until I came here, where many of my very old patients have it one form or the other. It's profoundly sad seeing someone struggling to hold on to the bits of pieces of themselves and failing. In the span of my three months here, I have seen many people falling into the entire spectrum - from those who are just beginning to gradually slide into short-term memory loss to those who have to be placed in higher level care because they would be otherwise a danger unto themselves. As heartbreaking as it is to watch as an outsider, I can only imagine how it must be for the patients' families and caregivers.

Strange as it may sound coming from a doctor and someone in the general business of prolonging life, dealing with older patients has made me realize one thing: I do not want to live to grow that old. Friends and I often morbidly joke that the best way to go is by sudden cardiac death after you've been old enough to enjoy life and a bit of your retirement - you won't even know what hit you.

Don't get me wrong, I don't mean any disrespect. I do want to live a long and active life, and I hope to be healthy for the most of it. But I don't want to live long enough to feel my knees, hips, and back start to go even with the aid of modern surgery; don't want to live long enough to lose control over my bodily functions; don't want to live at all if living means losing myself mentally little by little. I admit that this mind-set and very personal preference sometimes makes me wonder if maybe some of the patients who we treat full-on feel the same way.

Having come from a system where financial constraints often dictated the extent of what could be done for our patients and the choices were often limited and thus more clear cut, working here has been different kind of challenge. In this health care system where in medical care the sky is the limit, doctors treating these kinds of patients are faced with many difficult questions.

Issues like pre-morbid quality of life and projected quality of life after admission are no longer trivial questions asked for mere completion of a patient's personal and social history but very important pieces of information that are core to the medical team's approach to management.

I've heard it said often that one of the hardest lessons a doctor must learn in his lifetime of practice is knowing when it is best to fight harder and when it is kinder to let go. In this environment of relative abundance in medical technology and resources, I think that maybe it becomes even more challenging lesson to learn.