L'Chaim...

So I'm in the middle of a two-week stint of Geriatrics right now. The topics of the day invariably surround the most depressing parts of medical practice. We have the incurable chronic conditions, the terminally ill, the demented, the depressed, the disabled and the debilitated. How many times have I heard the term "health care proxy" this week? I can't even guess. Palliative care; "sedation therapy."

Which is more depressing - nursing homes or hospices? At nursing homes the residents are generally demented and seem to exist in a sad world of juice boxes, patronizing nursing staff and the pervasive smell of urine. A second childhood? Perhaps. More akin to a gentle warehouse where they wait for...y'know. At the hospice the patients are generally making the good faith effort to gradually complete their wretched existence which at the end revolves around their particular personal horror. Yet their families want them to die "with dignity." Ha. Dying with dignity is among the most mythic of all ideas. There is no dignity in death, folks. None at all.

Are these the successes or the failures of modern medicine? Thanks to modern medicine we've destroyed the previous strongholds of the Angel of Death. Infectious disease, once the major killer of humanity, has now largely fallen thanks to germ theory and antibiotics. Women dying in childbirth is today only a remnant of the merciless killer of a bygone era. What we are left with are the chronic conditions like heart disease, COPD, and cancer. We are so good at keeping people alive longer that more of them successfully make it to a state of debilitation and dementia. On the one hand, of course it is better that people live longer (and presumably better) lives today - but on the other hand, they weren't storehousing people in nursing homes and hospices in the past. Of course we are glad when a person survives an ordeal that would have easily taken them in a previous century, but we then all too likely send them on their way to a possibly worse ordeal before they take their final leave. Better? Depressing. The Angel of Death is less brazen today, but he makes up for it by being more sinister.

There is no mystery for why this is so. Evolution via natural selection is a great problem solver but it applies its solutions jealously only towards the primary goals of survival and procreation. The human body is incredibly complex and works amazingly well - but only for the first few decades of life. Y'know, the decades where the procreation and raising of young takes place. After the children are grown the elder generation no longer serves a much adaptive role. They are expendable. Natural selection stops working its problem solving magic on the likes of grandparents and soon enough the human body breaks apart on predictable fault lines. If the human body is like an automobile - modern medicine has largely cured the likes of a head-on collision, but after driving hundreds of thousands of miles even the best designed car will be totaled by an accumulation of wear and tear.

Ideally the purpose of medicine is to cure disease - not to let disease win. Yet palliative care is about letting the disease takes its natural course while treating the symptoms. Perhaps we need to recognize our limits since medicine today is still remarkably primitive in many ways, but palliation is still the real booby prize of medicine. The patients suffer less but they still die. There are no victories, only slightly less bitter defeats.