William Osler is famously quoted as calling pneumonia “the old man’s friend,” because it provided a relatively swift and painless death. Today, however, pneumonia has become just one more enemy in our unrelenting and often thoughtless pursuit of longer life. A 2007 Harvard Health letter reports, with no discernible irony, that Osler’s comment “was over 100 years ago. Today, vaccines, antibiotics, and improved supportive care mean doctors can do a lot more about pneumonia.” Goodbye, old friend.
Recently, I gave a talk about Alzheimer Disease at a medical school. There were about 80 people in the zoom room and, as I usually do, I began with a thought experiment. I told them about three people, and then asked them which of these three they would prefer to be. Marty, as I called him, died suddenly at age 85 of a heart attack, while he was still cognitively competent and living independently. Sylvia was diagnosed with Alzheimer at age 85, and died of natural causes at age 90, while in the moderate stage of the disease and living in a nice memory care center. Betty was also diagnosed with Alzheimer at 85, but she lived for ten more years, dying at 95 while in the final stages of severe dementia. Only one person in the room would prefer to be Betty. Two-thirds would prefer to be Marty, and one-third Sylvia. In other words, two-thirds of the people would prefer to die before becoming demented, even if that meant a shorter life, and the final third would prefer to die before the dementia became severe.
I have given a lot of talks like this, and the numbers always come out more or less the same. Of course, this is anecdotal evidence, and with academic audiences. I am currently engaged in a project to ask the same sort of questions with more randomly selected Americans, and I look forward to those results. Meanwhile, I think the responses I get are at the least very provocative.
There are some published studies that come up with results that can flesh out this picture. A 1997 study of over 9,000 seriously ill people discovered that 26% were “very unwilling” to live in a nursing home, and 30% would “rather die.” A 2016 study of seriously ill but cognitively competent people found that a majority believed that either incontinence or “being confused all the time” were states equal to or worse than death. A 2019 project found that about a fifth of participants who discovered that they had elevated amyloid-B, and thus a higher risk of getting Alzheimer, expressed interest in physician assisted suicide.
In other words, there are a whole lot of us who think that, if we were demented and/or unable to live independently, we would actually prefer death. Since physician assisted suicide is not available to people with dementia, it seems that “the old man’s friend” could be a welcome visitor. Could the novel coronavirus be today’s old man’s friend?
This is an important question right now, as society grapples with how to allocate vaccines against the virus. The idea that someone suffering from dementia and confined to a nursing home might actually welcome death is apparently so taboo that it cannot be openly contemplated.
A recent study from Careport Health
found that “in the nursing home population, dementia appears to be associated with a 1.7x risk of death, even after adjusting for age.” The response, of course, has been—let’s get those people vaccinated! But what about informed consent? Given the results I have laid out above, it appears that many, perhaps the majority, of people, would rather die than live in a nursing home with dementia. For them, refusing a vaccine is the logical thing to do. Of course, because they have dementia, they are no longer capable of logical thinking. But if they had taken the trouble, while competent, to appoint a healthcare proxy and communicate their wishes clearly, it should be obvious to the proxy that they would not want the vaccine.
I understand that, because vaccines protect others as well as ourselves, this is a more complicated question. I am one who would rather die than live in a nursing home, and I would certainly rather die than live with dementia. So, if I were incarcerated in a nursing home in the earliest stage of dementia, while still capable of making decisions, I would definitely refuse the vaccine and embrace deliverance via Covid-19 with open arms. That does, of course, put others at risk, including underpaid, dedicated healthcare workers. But then the best use of these precious vaccine doses is to put them in the arms of the healthcare workers, not in the arms of residents who may not want them.
 Mattimore, TJ, Wenger, NS, Desbiens, NA, Surrogate and Physician Understanding of Patients’ Preferences for Living Permanently in a Nursing Home. Journal of the American Geriatric Society 1997 July; 45(7):818-824.
 Rubin E, Bueller AE, Halpern, SD. States Worse than Death among Hospitalized Patients with Serious Illnesses. JAMA Internal Medicine. 2016 Oct; 176(10):1557-558.
 Largent EA, Terrasse M, Harkins K, Sisti DA, Sankar P, Karlawish J. Attitudes Toward Physician-Assisted Death From Individuals Who Learn They Have an Alzheimer Disease Biomarker. JAMA Neurol. 2019 Jul 1;76(7):864-866.