Having the perspective of an on-the-ground practitioner who has worked in the health care profession for so many years can be instructive for us as we navigate the dying days of our lives – dying in both senses of the words, as the lights of life dim and finally are extinguished.

In: 33 Meditations on Death … notes from the wrong end of medicine, David Jarrett, reveals how to go gently into that good night. We fight tooth and nail to put off the inevitable, dreaming that medicine can work miracles, when we all know this cannot be the case, placing expectations on medicos like Jarrett that cannot be delivered in reality. These three extracts provide a glimpse into his world. They are sober reminders that people like Jarrett who work on the front line, have much to offer society, if we would only listen and pay closer attention to the facts, rather than attempting to make fantasies come true. In short we need to look death in the face and accept it for what it is, part of the rotation from one generation to another. David Jarret deserves a wider audience and the powers that be need to heed his message.

Ch 4 – Good Ageing

As a geriatrician I see mostly the wrong end of the elderly spectrum – the weakest and the most ill. Geriatric medicine has always had difficulty defining what it is. Everyone knows what a cardiologist or gynaecologist does. With geriatric medicine it’s a bit like explaining jazz. As Louis Armstrong used to say, if you have to explain it, you will never get it.

A recent proposal is that it must encompass the ‘Five Ms’, which fit neatly on the fingers of one hand.

Mind: dementia, depression and all the psychological problems of the very aged;

Medicines: all the polypharmacy, complications and side-effects of the various poisons we inflict on the frailest of the frail;

Mobility: helping to improve mobility by diagnosing the problems and managing them medically, surgically and with various therapies such as physiotherapy and occupational therapy;

Multiple complexities: the myriad age and disease-related problems that accumulate in humans with time like the barnacles on the keel of a boat; Lastly and perhaps most importantly, what …

Matters Most: that is, what matters most to the patient, which may not necessarily be going in with all guns blazing offering all the investigations and treatments at our disposal.  Page 31 and 32.

Ch 22 – The changing landscape of care

How will our health service change for the elderly? The future is already here. I am not one life’s optimists, I admit. In my view, optimism is humankind’s great self-delusion. And when I look at the future state of the health service in the UK it is easy to see it being completely swamped by demand. Although much of the demand is due to demographic change and increased life expectancy, not all of it is.

….. modern medicine seems to be focused on trying to wring the last drop of life from the already desssicated existences of the weakest and oldest in our society – of how people within a few months of death, with little chance of any meaningful extension of their lives, and no semblance of quality, are being subjected to complex and draining interventions. Just because a treatment can be done, doesn’t mean it should be done. There is a burden of disease and there is a burden of treatment, and these two need to be balanced. Interventions that can be borne by a forty-year-old may be little short of torture for an eighty-year-old. A shift in attitude towards a more traditional view of death would free the health service from its current role of overseeing the time-consuming and costly overtreatment of those with little if anything to gain from it. Medicine, and especially medicine dealing with the very old, should be about what matters most in people’s lives. This should be our priority.  Page 190-191

Ch 24 – Dying a la mode

Something remarkable will happen after your death. Not just the slow decay and conversion of your buried body unto the flesh of worms and then into the flesh of robins or blackbirds. If you are cremated, the minerals will still enter some food chain or geological cycle grinding on over millennia. What will happen is that all those grim memories others have of you, of that disoriented, crumbling, incontinent old person, will be replaced by memories of what you truly were. People will recall the good father, telling bad jokes and helping out in a crisis, the mother and friend who always showed kindness when it was needed. Just as we cannot remember pain with any clarity, those distressing memories of you in your decline will in all probability fade. This reality-denial malarkey (nonsense) must have some benefits after all. .

With the passage of time, fewer and fewer people will have any personal recollection of you. When your last grandchild dies there will probably be no one on the planet who has had any direct contact with you. If you are a great thinker, writer, actor or musician your work may last a few hundred years or a million or two. But eventually as it was for Ozymadias*, ‘Nothing beside remains. Round the decay of that colossal Wreck … the lone and level sands stretch far away.’ I, for one, take some comfort from this.  Page 208

*”Ozymandias” (/ˌɒziˈmændiəs/ o-zee-MAN-dee-əs)^[1] is a sonnet written by the English Romantic poet Percy Bysshe Shelley (1792–1822). Wikipedia.