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Bilbo Baggins and My Old Dad: Some Not So Random Thoughts from a Geriatrician in the Time of COVID ‐19

2020; Wiley; Volume: 68; Issue: 10 Linguagem: Inglês

10.1111/jgs.16758

1532-5415

A. Mark Clarfield,

Neuroethics, Human Enhancement, Biomedical Innovations

I learned from my aged father that one can indeed live too long. For my part, he could have gone on forever, but it became increasingly difficult for me and my two loyal siblings to watch his demise. In Dad's final week we, stayed by his side as he had always been by ours. The old soldier took a deep breath, blew a fleck of sputum onto his lower lip, and stopped breathing. Almost 70 years old myself, I cried like a baby—as much for my loss as in relief that his struggle was over. Just shy of 100 years old, Dad's death coincided with my own retirement and offered me pause to think—about my patients, triumphs, and mistakes and about what he had taught me about being a physician, a father, and a son. Probably unfamiliar with Gladwell's "blink" strategy, Dad was quick to judge people based on two strengths: their sense of humor and handshake. Toward the end, both of his were clearly flagging. He taught me not only how to tell, but, how to listen to a joke. Even if you knew the gag, never let on. As Hemingway put it, "Most people never listen" but even as an increasingly deaf old man, Dad sure could. Not just an "active listener," he could also tell a terrific story. His delivery alone, well before the punch line, would send us into paroxysms. Sadly, toward the end, Dad's performance was beginning to flag. It was increasingly trying, watching him struggle with his gags—especially those that so easily used to trip off his lips. This was not Alzheimer's disease (yet), but I was observing the beginning of significant cognitive decline. We geriatricians also assess frailty, using measures such as grip strength to evaluate it. Dad's valuation of a firm clasp recalls the pioneer Scottish geriatrician Bernard Isaacs' observation: "[A] hand-shake is both a greeting and a diagnosis." Despite several long-standing age-related maladies (hypertension and ischemic heart disease), Dad lived for nearly a century without exhibiting any real frailty. Only toward the end did I sense a waning of his century-old vigorous grip. He also believed that one's trials be borne with fortitude. Any challenge, like upcoming surgery, would elicit the characteristic growl, "I'm a soldier…. and I just have to go through with it." He always did. And like so many members of this "Greatest Generation," he volunteered during World War II to join the Canadian forces in 1940, serving in the artillery. "Not just a sergeant, son, I was a Master Sergeant!" he'd growl. From him, I learned to do my duty and, staying within the metaphor, to bite the bullet. How he would have soldiered on with COVID-19, cut off from his beloved kids and even more adored grandkids and great- grandkids, I do not want to speculate. Remarkably, my father's older sister, our unstoppable 103-year-young Aunt Rose, was recently discharged after recovering from COVID-19; she is among the few people in the world who has survived both the 1918/1919 and 2020 pandemics. Although the bug did not kill her, the loneliness and sense of isolation nearly did. Her little brother's deafness and total inability to master any online gadget might have brought him to his knees. We are grateful that Dad died before this virus could have separated him from us. Although I doubt he ever knew who Sir William Osler was, my father also taught me the wisdom of striving for that great clinician's valuation of aequanimitas. In Osler's opinion, no matter how dire the situation, the true physician was meant to stay calm, lest the patient be rendered anxious.1 Dad fully subscribed to this notion. And even if I could not always reach that exalted state, his example taught me to put on as convincing an act as possible in front of my own patients. Typical of his generation, self-control was paramount. Also characteristic of his 1920s birth cohort, Dad began smoking at age 11 years (!) and continued for more than 30 years. As a child, I recall us discussing my own bad habit du jour—thumb-sucking. Dad gently explained that many people often developed behaviors—some good and many less so, his own smoking an example of the worst kind. He empowered me by explaining that we both had a difficult task ahead. After that chat, I let my thumb be, whereas Dad, with characteristic resolve, gave the middle finger to his cigarettes. My father loved to play all kinds of sports, with these activities likely contributing at least in part to his extreme longevity. Dad's favorite was golf—shooting in the low 80s in his high 80s and high 90s in his low 90s. From him, I learned the art of playing hard and losing well. Although always a keen competitor, he taught us the advisability of sometimes throwing a match—especially in favor of a superior on my way up the institutional ladder or looking down, offering an encouraging hand up to a junior colleague. As well, typical of his generation, Dad loved to drive but was suspicious of technology. For a good chuckle, watch the short clip of Dad's eldest grandson taking him for a ride in his new Tesla.2 In his view, and with much sadness I had to concur, at 99.5 years old, Dad's life had simply gone on for too long. As another of his generation, Bette Davis, had put it so well, "Old age ain't no place for sissies." And now COVID-19 is cruelly reminding us of this terrible fact of life. Indeed, I often wondered and Dad's example made me think anew that perhaps health professionals trying to help older persons do not always get the balance right. Perhaps we try too hard: to diagnose, treat, reverse, and rehabilitate. Maybe we should simply take the straw off the old camel's back (Figure 1). I have found that novels can help us deal with life's slings and arrows. One in particular helped me while watching dad's slide downhill. At the beginning of The Lord of the Rings, members of the Shire are celebrating Bilbo Baggin's 111th birthday. Although Frodo's uncle had received many compliments on how well he looked despite his long years, the Faustian antiaging effect was due to the malign power of "the rings." Having the wisdom to rid himself of this poisoned circular chalice, Bilbo sent it for destructive recycling with his young nephew Frodo—providing the theme for one of the most exciting Bildungsromans of English literature. Tolkien describes Bilbo's surprising vigor—this despite his advancing years: "Time wore on, but it seemed to have little effect…At 90 he [Bilbo] was much the same as 50." The author offered that this was not normal aging; rather, it was ring induced. Nevertheless, Bilbo admitted that, " … although he did not look his age, he was beginning to feel it in his heart of hearts. 'Well-preserved indeed! … Why, I feel all thin, sort of stretched, if you know what I mean: like butter that has been scraped over too much bread. That can't be right.'"3 For my old father, it certainly was not. Stretched thin himself over a century of history and life's travails, he would have agreed with the old Hobbit.