Death and the Older Internist

Are you really thinking about retiring?

Yeah, I don’t want to work until my final days.

But we’re not that old.

Yeah, but you never know how long you’re gonna last.

Early in my career, I realized that my job affected my approach to my own health. It probably makes temporal sense, therefore, that now I recognize how much my work affects my view of death – and how that impacts my life and practice.

Because I’m not a trauma surgeon, or an oncologist, or a geriatrician, for much of my career the death of a patient was, if not rare, only occasional. This has changed recently. With a practice of around 800 people, most of them over 75 — and many over 85 — I’m confronted with a death, or a new life changing diagnosis, almost weekly. One might imagine that the challenge of this is living with all the death and destruction, the Sturm und Drang, but, after 30-plus years in practice, this is surprisingly easy.

That said, what happens in my practice affects my life in other ways.¹

Maybe it is more age than clinical experience, but I have never been more comfortable with the idea of my own death. I witness enough death that I can’t help thinking about how I want to go. Ideally it will happen at a time when my life has naturally shrunken, so I don’t mind not being able to travel. I’ll be diagnosed with a relatively painless cancer, allowing me some weeks or months to sign out (like my father did).²

If my death comes too early, please let it be sudden. I don’t want the time to grieve for (or my likely rage against) all the things I still want to do and see, the people I want to spend more time with, the conversations I want to have over good meals.

If my experience is worth anything, however I go, I’ll want more time and will have a hard time sacrificing even “low-quality” life for a better death.

Though I still feel young — physically and emotionally — my maturing awareness of mortality has made me feel older than many of my non-medical peers. I see the uncomfortable looks when I allude to the finite amount of time left and the need to consider it when we plan our remaining time. (Yes, I am sometimes not the person you want at your party).

We all treat the ends of careers differently. We all have different pressures: financial, caregiving, bucket lists. I have seen enough doctors “fail retirement” to know that we, as a profession, don’t have any special insight into how and when to call it quits. I am sure that if I make a mistake in timing retirement, my current clinical life will make me pull down the shingle too early rather than too late.

While I am still practicing, my exposure to death pays dividends and exacts costs. Most people, when they near the end, cherish the ability to just speak honestly about what is ahead, to discuss death without euphemism. I’ve lost count of the number of people who’ve lingered at appointments, cherishing the opportunity to talk forthrightly about the future. The thanks I have received after these conversations are among my most cherished.

There is a real downside with getting too comfortable with “this happens to us all” and “death is part of the human condition.” Although nobody gets out of here alive, each of us only dies once and we are rarely really ready to go. I have to fight becoming less sympathetic to the personal and family grieving that accompanies the passing of even our oldest.

I’ve appreciated every stage of my career, though some only in hindsight. I am trying to appreciate the privilege of caring for my aging panel of patients in the present, remaining mindful about how the experience affects both my practice and my life.

1. This footnote is in lieu of the obvious Severance reference I avoided.

2. This is a nice take on the sentiment.