Good and Old

            The solution to my dilemma was staring me in the face: if I didn’t find the new 

developments in medicine of sufficient interest to blog about, and if I didn’t think my readers

—a motley collection of people interested in aging—would find those developments of great 

interest either, I should write about great books. I would re-read the books that influenced 

my thinking twenty or more years ago. After all, just because the ideas in those books have 

become integrated into my world view, just because I take them for granted, doesn’t mean 

they are trite or passé. Nor should I assume that most people, particularly the younger 

generations, are familiar with those seminal ideas.

            I first realized that not everyone who cares about old people—not even everyone 

trained as a specialist in caring for older people—has read what I consider the great works 

of geriatrics, whether books or essays. Several years ago, I was giving a talk to a group of 

well-educated, exceptionally smart and ambitious young doctors and I mentioned the 

longstanding disconnect between the kind of care patients say they want near the end of life 

and the kind of care they actually get. I traced the history of the recognition that such a gap 

existed and reviewed the early strategies for overcoming it, so of course I referred to the 

SUPPORT study. The faces of the well-educated, exceptionally smart and ambitious young 

doctors looked blank. Hesitant to go over well-trod ground, but not wanting to make any 

unwarranted assumptions about what my audience knew and what they didn’t, I asked how 

many of them were familiar with SUPPORT. Not a single hand was raised.

            The SUPPORT (The Study to Understand Prognoses andPreferences for Outcomes 

and Risks of Treatments). The study was a large, randomized trial conducted at 5 U.S. 

hospitals and involving over 5000 very sick patients, people who had one of a handful of 

conditions and a high likelihood of dying within the next year. Phase I of the study 

established that a majority of these patients, provided they were informed of their prognosis 

(which few had been) favored certain limitations of treatment but that only a minority 

received treatment that accorded with their wishes. Phase II of the study showed that when 

specially trained nurses told patients their prognosis, elicited their preferences, and 

transmitted those preferences to the attending physician, the lack of concordance persisted. 

As an intervention trial, this multimillion dollar, Robert Wood Johnson Foundation supported 

study was a resounding failure. But as a descriptive study showing, for example, the 

proportion of seriously ill people who died in pain or despite invasive technology, it was a 

landmark work. And the failure of the particularly remedy was also illuminating. 

            SUPPORT is now 25 years old but it was crucial to all subsequent work in the area 

of advance care planning, It defined many of the norms by which “good” end of life care 

would be measured. It launched the careers of numerous researchers who struggled to 

understand why SUPPORT flopped, on the one hand, and how to achieve its aims in the 

future, on the other. The truth is, we are still today trying to figure out how best to explain to 

patients the way their diseases are likely to unfold, what their options are, and to help them 

translate their personal values into a viable treatment plan.

            Ignorance about SUPPORT is no anomaly. Last month, Daniel Callahan died, one of 

the giants of American biomedical ethics. I am old enough to remember reading his 

controversial book, Setting Limits, when it first came out in 1987. At last, I recall thinking, a 

philosopher who is not floating in some abstract universe of ethical principles, but who is 

grounded in clinical reality. I also remember browsing in my local bookstore, which 

somewhat bizarrely shelved its books according to publisher, regularly seeking out the 

Simon and Schuster section, eagerly awaiting Dan Callahan’s next book. I read them all and 

eventually I got to know Dan Callahan himself, as kind, generous, and modest as he was 

insightful and path-breaking. So, I was shocked and dismayed to realize that young 

physicians today, even those with a background and interest in ethics, typically know that 

Daniel Callahan co-founded the Hastings Center, the foremost American biomedical ethics 

think tank but have never read Setting Limits.

            So we come to the new plan: I will write about the classics. Not the Iliadand the 

Odyssey. Not IL Nascher’s book, Geriatrics: The Diseases of Old Age and Their Treatment, 

which laid the groundwork for a new field but which is now hopelessly out of date. Instead, I 

will peruse my own bookcases and write about those books that deserve to be read and re-

read. I will get to Setting Limits soon. But the first book I’d like to blog about was not written 

by a geriatrician or a philosopher nor a historian, but by a novelist. It’s Patrimony by Philip 

Roth and it’s one of the finest depictions I have ever encountered of frailty, on the one hand, 

and of the perils of medical decision-making on the other. It is one of Roth’s only forays into 

non-fiction and in it he tells the story of the final year in the life of his father, Herman Roth. 

Reading this fine book now is particularly poignant because Roth Senior was 86 in the 

narrative and Philip Roth, the son, died a year ago at age 85.

            WhatPatrimony is really about is the relationship between a father and a son, which 

may not seem like a geriatric issue. But from my perspective, relationships are the 

quintessential geriatric issue. One of old age’s principal challenges is to find meaning in life, 

often in the face of loss, illness, and disability. One of the principal sources of meaning is 

relationships, and what relationship is more profound than that between a parent and child. 

What makes Patrimony  so special is that Philip Roth, who sounds as though he had for 

years found his father endlessly annoying: he was not an intellectual, he had a habit of 

constantly correcting and cajoling those he cared about, and he simply wasn’t interested in 

the same things as Roth Junior. But over the year that Philip shepherded his father from his 

brain tumor diagnosis to his eventual death, he came to accept his father’s foibles and to 

appreciate his strengths. It is with affection and understanding that he reports his father’s 

penultimate question to the neurosurgeon he saw in consultation about the tumor: “What do 

you use to go in there? Do you use General Electric or Black and Decker?”

            The book shows us how painful loss is—and why we are so reluctant to let go. When 

driving from New York City to Elizabeth, New Jersey, where his father lives, a route he has 

taken countless times, Philip Roth makes a wrong turn and ends up at the cemetery where 

his mother is buried. He visits his mother’s grave and we see that though he is a famous 

author, financially successful and, at least during the writing of the memoir, enjoying a 

fulfilling romantic relationship, his mother is still “Mommy.”

            Roth the novelist is known for raw and explicit details, usually in the sexual arena. In 

Patrimony, he is raw and explicit in his description of his father’s difficulty chewing and 

swallowing and of a bout of incontinence. He shows the devastating loss of dignity that 

makes frailty so difficult to endure—and how acceptance of his father, despite his difficulties, 

is the way to transcend frailty.

            Finally, Roth’s book shows how the medical profession pushes patients and families 

toward aggressive treatment. Surgery to remove Herman Roth’s tumor is variously 

described as requiring an 8- or even 10-hour operation or two multi-hour procedures, either 

way, an unequivocally major ordeal. But surgery, from the medical professional’s 

perspective, offers the only path to improvement, though the likelihood of achieving 

improvements is not great and the chance of surgery making things worse is considerable. 

As the story unfolds, the Roth family gradually come to see that the best course of action for 

the 86-year-old Herman is supportive.  There’s even a poignant acknowledgment that 

advance care planning is often harder for the family than for the patient: Philip Roth 

struggles for days to discuss a living will with his father. He says it was harder for him to 

broach limiting treatment than it had been to talk about the brain tumor diagnosis. With the 

tumor, he could behind terms such as “benign,” ignoring the reality that even non-malignant 

growths can cause plenty of mischief and conveniently neglected to mention that the tumor 

was enormous and had already encircled a major blood vessel in the brain. When Roth 

finally does raise the subject of advance planning, he finds his father is matter of fact about 

the process and quite comfortable with setting limits. Herman had sold life insurance for a l

iving; he had “spent his life time talking to people about the thing they least wanted to think 

about.” So, even though Herman Roth can’t resist hoping for “another couple of years” and 

then, by the time he goes for a second opinion, for “3 or 4 years,” he’s a realist and knows 

that the end is coming. As he says, once he’s dead, he won’t have anything to worry about. 

It is his son who will suffer afterwards, who will continue to feel love, affection, respect—and 

loss.

            Patrimony is a geriatric masterpiece. First published 28 years ago, it is not in the 

least bit dated. Father/son relationships, frailty, advance care planning, and death are all still 

around and always will be.

Loss

There will be no more email messages with requests for data about the median age of legislators in Western European countries. No emails with provocative observations about the association between the rise in the overall suicide rate and the growing legalization of physician assisted suicide. They all began with “Dear Muriel,” never with “Hi Muriel,” never without a salutation. He is gone, I learned in July. Died just before his 88^thbirthday. It was the emphysema that got him in the end.

I realized last night that I haven’t written a single blog post since then. For some time, I’ve been finding it difficult to identify new findings in medicine worth writing about, that is, sufficiently interesting to me to write about them. Vitamin D is the panacea for aging; Vitamin D is out—useless, or worse. Calcium prevents osteoporosis; calcium doesn’t prevent osteoporosis. At long last, Congress passes legislation supporting caregivers; the new legislation won’t achieve much of anything. There’s a new, promising test to identify pre-clinical Alzheimer’s disease; there’s no point taking the test unless you want to enter a research study—or if you want to make yourself miserable sooner than necessary. None of this seemed to matter enough for me to write something about it. And now it matters even less because there is a hole in the fabric of the universe.

For years, I’ve been writing about meaning in old age: the importance of figuring out ways to remain engaged with the world despite age-associated limitations, despite encroaching frailty. I’ve consistently seen the role of geriatrics as facilitating a good old age, where 'good' implies a time to cultivate relationships and contributing to the net goodness in the world. Geriatrics is the means to an end, not the end itself. Sure, preventing or reversing frailty would be nice, but what is even more critical is adapting to whatever life has in store for us, and that's the domain where geriatrics, like palliative care, can make contributions. I’ve also written about accepting mortality, which applies both to people who themselves are facing the end of life and to those who care about them. But I don’t think I’ve said anything about how to cope with loss after death.

I suppose that as a physician, I’ve seen my role as ending when life ends. Dealing with what comes next, whether for the person who has died or for everyone else, that’s someone else’s domain. That’s for religion or psychology or social work. But now I’m facing a hole. Yes, I recognize that life is finite. Yes, birth and death, growth and loss are all natural, normal. But we humans, we are meaning-makers. We need to make meaning out of life even where there isn’t any. We do this with rituals, with ceremonies, with reminiscences. We immortalize the mortal through our memories. So, I will do what I usually do when confronted with something that I see as important: I will write. My writing will not patch the hole, but perhaps it will serve as a sort of ornamental curtain.

Rest in peace, my friend.

Daniel Callahan, pre-eminent bioethicist and a true mensch, died on July 16, 2019.