“People generally die the way they live,” says nursing professor Sarah Kagan. We are seated in her office in Claire Fagin Hall, listening to Haydn on her computer and to a cellphone that occasionally quacks like a duck.
Kagan, the Ralston House Term Professor of Gerontological Nursing at the School of Nursing and clinical nurse specialist at the Abramson Cancer Center, received a coveted MacArthur Fellowship in 2004 [“Sarah Kagan’s Genius Idea,” Mar|Apr 2004]. Recently she has come out with her second book, Cancer in the Lives of Older Americans: Blessings and Battles (University of Pennsylvania Press). One of her themes is that people’s basic personality traits don’t change as they get older, but they do manifest themselves differently because of different circumstances. She thinks this merits more explicit attention in medical training.
When families ask her what the end is going to be like, Kagan often starts her response with a query: “Tell me what your mom or dad is like.” This “often opens a conversation I have found profoundly useful.”
In her new book, Kagan tells us the story of Mrs. Eck, a woman in her eighties who lives in New Jersey with her husband of many years and who is surrounded by a large and loving family. Home is very meaningful to her. Mrs. Eck has pancreatic cancer. She deals with it bravely, but it is only a part of her life. Or, as she puts it in an interview with Professor Kagan, “I didn’t let it get me down. ‘Cause I just said, No, I’m going to take this one day at a time. I’m going to try to get up every day and see what the day brings.” In the end, Mrs. Eck’s goal is to get well enough to get out of the hospital, so she can die at home, in the same room where her mother died many years before. And she succeeds.
In Mrs. Eck’s case, the circumstance of pancreatic cancer is of course extraordinary, and eventually terminal, but it is only part of the rich tapestry of her life, and she deals with it using the same coping tools that she has developed over more than eight decades of living.
What does it mean to be old? Well, old people certainly differ from their juniors in a number of ways. Biologically, for instance, they metabolize food and drugs differently (think Centrum Silver). Medically, they often have several chronic conditions that require treatment—glaucoma, osteoporosis, diabetes, and hypertension, among others.
And they are prone to cancer. “Advancing age is the single greatest risk factor for cancer,” notes Kagan. “The older you are, the more likely you are to be diagnosed with cancer.” But cancer is no longer the death sentence it once was seen to be. Of the four major cancers—breast, lung, colorectal, and prostate—all are treatable. With early diagnosis, colorectal cancer is frequently curable, and prostate cancer has been known for years as the cancer that men generally die with but not of. “Approximately half of those of any age diagnosed with cancer today go on to survive it,” notes Kagan, “and many older adults diagnosed will die of a cause other than their cancer.” Not surprisingly, in these circumstances, “People do not become their cancers.”
Instead, the cancer becomes a part of their ongoing life, along with the glaucoma and the grandchildren.
So we can mark off a zone of life called old age. But when does it begin? Is it 62, when Americans become eligible for Social Security? Or 65, when they become eligible for Medicare? These are significant milestones, but they are social constructs. What about the aging of the body? As Kagan points out, “Aging is a biological process that occurs throughout the life span.” Just as the advent of bifocals can be taken as a marker for the beginning of middle age, perhaps there are sentinel events that we can agree mark the beginning of old age. But what are they? Is a 60-year-old who is dying of cancer old, or middle-aged?
Likewise, we can often mark off a subzone of old age—the terminal phase, lying between a final diagnosis and death. Even here, as Mrs. Eck’s story shows us, some old people will resist being defined by their disease, even when clinicians, as Kagan puts it, “treat them as though they have nothing in their lives but cancer treatment.”
Old people do have a realistic knowledge that they will die at some point. This distinguishes them from the young, who assume they are immortal, and from the middle-aged, who merely hope they will live forever. Kagan emphasizes that while the old have a different perspective, “it is still about life.”
Kagan leaves me with one more intriguing thought: the idea that medical training currently focuses on the wrong people. Today the assumption is that the patient is relatively young. Old age is added on as a complicating factor.
But what if the typical patient is 75, and not 25? Well, take a look at who’s coming through the door at the typical hospital today. The paradigm shift has already taken place in the real world. Now school just needs to catch up.
—William K. West