Being Mortal

Four times a year I go into one of the Southern Medical Laboratories offices and have a sample of blood taken. Someone in a lab somewhere then measures my levels of cholesterol, blood sugar and uric acid. And they look for the one I am really interested in: my levels of Prostate Specific Antigen. PSA is produced only by the prostate gland, and seeing as I have had mine removed, if there is any PSA in my bloodstream it can have come from only one source: prostate cancer cells that have drifted off through my lymph system and are now lodged and growing in some unknown part of my body. About three years ago my PSA levels, while still comparatively low, were increasing alarmingly, doubling every four months or so in a pattern which, if not  dealt with would have proven imminently fatal. My urologist started me on a course of hormone injections which reduced the levels immediately to zero, where they have stayed since.

While the hormones deal to the overwhelming majority of cancer cells, a few are impervious, and they will be there, slowly and microscopically increasing until they are detectable. My PSA reading will stay at zero for "some time", but no-one can tell me how long "some time" might be. The average seems to be about three years, which is about now, but who knows? Ten is possible, even  longer, But one day the blood test will reveal a number greater than zero, and that will mean I am already embarked on a process whereby the hormone proof cancer cellswill grow exponentially until they kill me - not immediately but over a shortish span of years.

So I go into the little room, sit in the overstuffed armchair, watch as the friendly woman inserts her needle and I play my three monthly game of Russian Roulette. I can use Google, so I have a pretty fair idea of what death from prostate cancer looks like. It will be like most modern deaths, OTAA, that is, One Thing After Another. My body will fail, and the doctors will fix it, only to have it fail somewhere else. There will be an escalating game of punch and counter punch until the end, as it inevitably must, arrives. It's an odd thing to have a reasonable idea of how I will die, although, if you think about it, this knowledge is not unique to me. In the West, in the 21st Century, almost everybody will have a OTAA death.

A few months ago I visited the cemetery in Hamilton South, a now defunct town in the Maniototo. I noted that in the first 23 years of the cemetery's existence there was no-one buried who was older than 60. In the last 50 years of internments there were only 2 who were younger than 60. Patterns of life and death have changed. Only a couple of generations ago, death was usually unheralded and swift in its arrival. Now it is, typically, a prolonged affair as drugs and surgery are used to prolong life with interventions which are increasingly expensive and decreasingly effective. We'll all have the pills, and the oxygen bottles and the various appointments with a very sharp knife. We'll all have things happen to us which are painful, and which will win us a longer life, though often only slightly. We will become part of systems which seem hell bent on keeping us alive at all costs, even if that life is... hell. We'll all ask whether or not it is worth it.

Dr. Atul Gawande is a general surgeon who seems to have had a lot of experience dealing with very elderly people. His book Being Mortal presents the issues surrounding our own mortality and our seeming inability to admit to it. The book is anecdotal, filled with case studies and character sketches, but it is nevertheless unflinching in presenting us the reality of death, and the futility of our obsessive efforts to defeat it. He spends a lot of his time discussing the issue of elder care, and the fact that safety, comfort and convenience, which seem to be the defining aims of many elder care facilities, do not necessarily provide the residents of such facilities with a life that is worth living. He presents some moving cases of younger people afflicted with incurable, debilitating disease, where the same issues are apparent.

Many of us are not good at facing our own mortality, and this book is a helpful way of allowing us to do so. For myself, I am afraid neither of death nor the cancer which is likely to be its cause. We'll take it as it comes.  I don't want anyone to go administering a suicide pill, but neither do I want any expensive and painful procedures that will keep me alive technically, but in no other meaningful sense. Sitting in the dark as we drove South on Sunday, prompted by Atul Gawande's clear, wise words on the subject, we talked about what is to come and made some provisional plans against that (I hope very  far distant) future event. This is what this book is good at provoking. For anybody who is facing death, either their own or someone else's (and of course, that is, ultimately, everybody) this book is a must read.