Sunday, August 21


Jerald Winakur, a practicioner of internal medicine and geriatrics in San Antonio, Texas, and on the faculty of the Center for Medical Humanities and Ethics at the University of Texas Health Science Center, has written the following, as published in today's edition of the "Houston Chronicle" (registration required) and as published in a longer, original version in the July-August issue of "Health Affairs":

In the United States today there are 35 million geriatric patients — defined as over the age of 65. Of these, 4.5 million are older than 85, now characterized as the "old old." Yet the American Medical Directors Association, which credentials physicians in long-term care, has certified only 1,900 such doctors in the entire country; only 2 percent of physicians in training say they want to go into geriatric care. As we baby boomers go about our lives, frozen into our routines of work and family responsibilities, a vast inland sea of elders is building. By 2020 there will be an estimated 53 million Americans older than 65, 6.5 million of whom will be "old old." Many of you will be among them. America will be inundated with old folks, each with a unique set of circumstances, medical and financial.

Compounding all of this is the sad and frustrating fact that our government appears to have no policy vision for long-term elder care. It's as if our leaders wish — perhaps reflecting our collective yearnings as a vain, youth-worshiping society — that when the time comes, the elderly will take their shuffling tired selves, their drooling and incontinence, their demented ravings, their drain on family and national resources, and sprawl out on an ice floe to be carried off to a white, comforting place, never to be heard from again.

The thought occurred to me: since the vast majority of Roe v. Wade sanctioned abortions is owing strictly to the convenience of the mother, rather than life-threatening medical complications to her or her preborn, than what does this looming, tectonic shift in age demographics in America presage for the elderly among us (i.e., the "old" and the "old old") absent a majority of strict constructionists on the United States Supreme Court protecting them?

Surely, if a warm, cuddly, thoroughly dependent baby boy or girl has been and will remain anathema to millions of healthy, expectant mothers in our land, than what will those same women (and their male partners in wrongdoing) contemplate in the face of the needs of geriatric parents?

As Dr. Winakur writes of his own father:

But every week he gets worse, harder to deal with, more bizarre. Recently, he has begun to holler at my mother every time she tries to help him change his clothes, which is often because he wets himself. "You're my sister! You're not supposed to see me naked!" he screams at her.

From my years as a geriatrician and now as the son of an "old old" man, I recognize that there is one inescapable truth: Our parents will become our children if they live long enough.

I don't know what else to do for Dad at this moment, but I can imagine what is likely to happen to him if he does not die in his sleep. One day I will get a frantic call from my mother that my father is on the floor and crying out in terrible pain. I will race over there. I will find that one of his legs is shortened and externally rotated. His hip is broken. I will call my brother and tell him all the reasons why we should not send him to the hospital: He might not recover from the surgery — he might die on the table, given his bad heart. If he does survive, he will spend days in the ICU, probably on a respirator. At best he will end up in a nursing home, bedridden, at the mercy of overworked, underpaid aides. He will descend deeper into disorientation, require medications to keep him from harming himself, and die anyway in a few months.

My brother will hear my mother crying and my father hollering. He will feel guilty that he is not there with me. Then he will say, "Maybe it won't be as bad as you think. Maybe we can set up a hospital bed in his room, and it won't take much to alter the shower to accommodate a wheelchair. (Pause.) I don't know. You're the doctor. What do you think we should do?"

I do not tell him that often, in fitful sleep, I dream that when the time comes, I go to my father's bed, quietly fill a syringe with morphine and stroke his arm as I tie the tourniquet. I tell him I love him and what a good father he has been to me as I slip the needle into his antecubital vein. Then I say how much I will miss him and goodbye, Dad, goodbye. In this dream I tell my mother and my brother that he has gone peacefully in his sleep.

Yet I have not until now given voice to this dream because I know, in the end, I could never do this. Not to my demented, suffering father. Not to anyone. I know there are some who disagree with me, and perhaps this is one way our society will ultimately deal with its flood of elders in this age of limits. I will by then, I hope, be old and no longer on the front lines. When my time comes — before it comes — I will choose for myself. But for now, as long as I have the will and the strength to practice, I am a physician firmly rooted in the art and tradition of healing, of comforting.

So instead, on that day, I will tell my brother that I will handle it and hang up the phone. Then I'll pick it up again and dial 911.

Sobering, discomforting, difficult to contemplate, but out there on the not too distant horizon. What does the gathering storm of nihilism, encroaching secularism, and diminished ethics portend for an aging America? If a doctor of geriatric medicine is having these kinds of dreams (but thankfully recoiled from them), what will liberal federal and state judges beset by the inconvenience, heartache, and expense of caring for "old old" parents do or rule?