The coronavirus pandemic must cause us to re-appraise the value we attach to the lives of others, especially vulnerable people and those who are old.
Time speeds up with ageing. A cohort of experience, contacts and past and present projects travel with us. In Anne Deveson’s book, Coming of Age, John Kingsmill said, “I no longer understand people of forty. I would love to have friends of forty. They would stimulate me enormously, and I might have something to offer them by way of mental stimulation. I don’t know, because I simply don’t know anybody of forty. I hardly know anyone of fifty. Most of the people I see are comparatively new friends, and they are all my age or older than I am.”
Well before dementia caught up with her, Anne Deveson interviewed 21 older Australians for her book – Mungo MacCallum, Tom Uren, Colleen Clifford, Charles Birch and others. They were all satisfied with the lives they had lived and valued the continuing relationships they had had. None felt old or behaved old, the fortunate ones. Research repeatedly shows that subjective well-being in elderly people belies the observers’ measures and expectations.
Ageing and time passing is conditioned by life’s accumulated experiences, exposures and impairments. In the mountains of Abkhazia, 100-year-old Alexey (age probably over-stated) carries a pail of potatoes up the mountain every day; in these regions people are proud to be old. John Olsen at 92 is a painter of masterpieces; Michelangelo at 88-89 worked on plans for the Church of Santa Maria in Rome. and Arthur Rubinstein recorded and performed in Carnegie Hall in his late 80s. Men and women in their 80s and 90s continue to wield power politically and through wealth.
Not everyone who looks old, is old. Not all of the advanced age are dysfunctional; most live worthwhile lives, as do writers for Pearls and Irritations. Those who reach old age have experienced lives of extraordinary richness.
Two old ages
Others wear out before their time. Women dependent on phenacetin-containing tablets – APC and Bex powders – became wizened and old before their time. Heavy smokers run downhill fast as lungs and heart deteriorate – they look old and die early.
When shown images of homeless people, medical students regularly estimate their ages to be 20 or more years older than they are. In Going Bad, Melbourne’s history of homelessness, Alan Jordan, found “Most the preliminary estimates of age made by police on discovery of bodies were widely inaccurate, overstating age by ten years or more. On examining the body of a 38-year-old man, the pathologist recorded that he appeared ten and perhaps twenty years older than that stated (and correct) age.”
Ageing is not truly in the ‘eye of the beholder’
Medicine is not immune from ageism. In the satirical novel The House of God, based on New York’s Beth Israel Hospital, portraying the dehumanising effects of hospital residency in the US, interns use ‘gallows language’ to deny their inadequacies and shame as they confront the intractable problems of patients.
The patients become ‘Gomers’ (Get Out of My Emergency Room); they are “the no-hopers who wanted to die but are worth more alive.” In the Casualty Department where I first worked, junior doctors would hide their inadequacies by labelling old people and others, as ‘old croaks’. Their education had failed them.
I too have felt ashamed. Glad to escape the cloying atmosphere of the nursing home – escaping but with an overpowering sense of inadequacy and guilt that I hadn’t done more. What do the hundreds of doctors think as they return to their practices after nursing-home visits? What do they think about of the conditions they’ve seen? And the nurses and aged-care workers who are there every minute of every day?
The inadequacies and failings of the “institutional” provision of care for frail elderly people have been exposed all too well in the Royal Commission into Aged Care Quality and Safety; so graphically described by family members and apparent to the doctors, nurses and aged care workers. The most significant recommendations of the Royal Commission relates to the primacy of the person, their autonomy, their cultural background, their location and history. The Commission has recommended a rights-based approach in a new Age Care Act.
There are privileges to being old. My grandmother, sitting beside the wood-fired stove would tell me stories of my uncles’ pranks on the farm and of fears of the ‘Kelly gang’. Since then, I have wanted experiences. Experience brings with it tacit knowledge – learning by doing – succeeding and failing – from patients and fellow workers, from stories.
As grandparents can calm the upheavals in family life, experience can bring equanimity to the hectic and risk-averse environment of modern medicine; a pause button to pay attention. Senior doctors with well-worn networks and skills can support younger doctors in areas of complex decision-making. Nowhere is this more important than in caring for older people.
In his famous 1889 speech, Aequanimitas, Sir William Osler, the father of clinical medicine, extolled the value of imperturbability, coolness, and presence of mind under all circumstances. He wrote, “The physician who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients.”
Geriatrics
Aged care workers undertake thankless and intimate tasks and deal with difficulties in the best way they can. They are of low status, poorly paid and stigmatised like the people they care for. The institutions in which they work are shunned and ignored.
In the 1950s and 60s, the medical needs of an ageing population were recognised and led to the birth of geriatric medicine; Glasgow University appointed the first professor of geriatrics in 1965. During the following half-century, geriatric medicine specialists have been appointed to mainly public healthcare systems – some in the community but most to hospitals.
And in the hospital, geriatricians are able to teach and show that the principal needs of sick ageing people are for comprehensive care rather than the narrow focus of super-specialisation. The geriatrician’s bread-and-butter role is to fill the gap.
There is much to change
Anne Deveson concluded her book, Coming of Age, “So let us be careful we don’t swap one set of stereotypes for another which might be equally limiting. I, for one, don’t want to be rolled in a marshmallow of euphemisms. I refuse to be known, as a senior citizen, a tribal elder, or a golden oldie. I would loathe to end my twilight years in a sunset village. I do not want to be caring and sharing. And I’m not growing older. I am growing old – a fact which I state quite mildly, but in protest against the saccharine brigade.”
Simone de Beauvoir was of a similar mind, “One’s life has value so long as one attributes value to the life of others, by means of love, friendship, indignation, compassion. When this is so, then there are still valid reasons for activity or speech.”
The Royal Commission into Aged Care Quality and Safety offers the opportunity to re-evaluate our attitudes to ageing and the policies and institutions which fashion the support and care of ageing people, especially our infirm aged.
Ian W Webster AO is Emeritus Professor of Public Health and Community Medicine of the University of New South Wales. He has worked as a physician in public and regional hospitals in Australia and UK and in NGOs dealing with homelessness, alcohol and drug problems and mental illness.
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