©March 2008

Seeking an antidote for aging has been a dream of humans since before Ponce de León searched in vain for the Fountain of Youth in Florida, followed centuries later by hordes of retirees from New York.  In fact, led by advances in sanitation, housing, and subsequently by the vaccination and antibiotic era, humans have enjoyed a fair amount of success by increasing life expectancy from 47 years to about 80 years over the past 150 years in developed nations.  While it is unfortunate that these successes have not generally been shared with countries left behind by modern advances, the World Health Organization and certain private foundations are currently seeking to more evenly distribute these achievements.  The challenge facing developed countries, in addition to helping to correct the disparity in public health resources between the wealthy and poor, is to continue to increase longevity while at the same time assuring that this increased quantity of time includes the promise of quality of life.  The fields of research are studded with disappointments, but also with some exciting new discoveries.

There have been several recognized changes in cells that occur as we age.  Many of these changes have been attributed to damage resulting from byproducts of the operations of our cellular machinery.  We know that a particular “handle” on our DNA, called the “telomere,” seems to shorten as a cell divides over and over again, leading eventually to cellular death.  We know that exposure to certain unstable molecules within the cell causes damage to cellular materials by oxidation, and thereby lead to shortened cellular life span.  This contributed to a search for “antioxidants” as a solution to aging, and resulted in the emergence of many advocates of mega-doses of certain vitamins.  However, recent research has not confirmed the promised benefits of high dose Vitamin E and Beta carotene supplementation.  While a number of genetic markers have been recognized as promoting longevity, the practical application of this knowledge to public health is only theoretical.

On the other hand, there are reasons for some hopeful optimism in this quest for longevity.  Work done in 2006 with the fruit fly and certain worms uncovered an enzyme system which not only extends life span, but also reduces the frequency of several diseases of aging, such as type 2 diabetes.  A search is underway for other molecules that stimulate the “sirtuin” enzyme system and several candidates have come to light, but much research is needed before any conclusions can be practically applied to humans.

Through research done with rhesus monkeys and other species, one intervention has been repeatedly demonstrated to have a positive impact on longevity.  Animals that consume a calorie-restricted diet live longer.  It is in keeping with Nature’s sense of humor that exactly the behavior most averse to affluent populations is the behavior which appears to have the greatest impact on increasing life span.  While solutions other than limiting food intake are being sought to extend lifespan, for the time being calorie restriction appears to be the most accessible option, if not the most marketable.

While these thoughts have not addressed the critical issue of quality of life, it is important that we flavor any increased duration of life with satisfaction.  We are again left with the task of deciding for ourselves what balance between time and quality provides us with the rewards we seek.

©November 2008

Sometime during childhood, the idea sneaks into our heads that we are participating in a game which has a beginning and an end.  Speaking strictly biologically, we are born, we live and then we die.  In an effort to underline the importance of what happens in the middle, Dr. Neil Shulman likes to point out that “life is but a dash between two numbers on a tombstone.  Make the most of it.” In keeping with this philosophy, there are issues pertaining to our mortality that are worth consideration.

One of the obstacles to having a truly objective view of the world is something that might be termed a “mortal perspective.”  To a three year old, one year represents one third of a lifespan.  Consequently, to the child, the time between one frosted birthday cake and the next is nearly intolerable.  To a 94 year old great-grandmother, this same measure of time is hardly as long as a good sneeze.  It is for this reason that the perceived halfway point in life occurs at a much younger age than the mathematical halfway point.

This “mortal perspective” provides a nice scapegoat for a lot of irresponsible behavior.  The so-called “mid-life crisis” is often attributed to middle-aged people gaining a view of the finish line.  A balloon payment on a 30 year mortgage can hardly be seen from the steps of the bank at age 50.  Even climate change is easier to understand when we recognize the unfathomable contrast between geological and biological time.  It is hard to feel personally responsible for our own tiny contribution to the atmosphere when we understand our visit here to be limited to a measly 80 years.  As they say, no individual snowflake is responsible for the avalanche.

Most of what we experience and perceive is measured by a widely-advertised and approximated 80-year life span.  Specifically, a female infant born in 2014 has an 81 year, and a male infant a 76 year life expectancy, averaging to a 79 year life expectancy for both genders together.  Life expectancy continues to show significant racial disparity, with the numbers for blacks being about 4 years less than those for whites.  Similarly, there is a significant discrepancy between people of high and low economic status, independent of racial factors.  These are important problems to address for the public health community, and are considerations to keep in mind as we address health care reform.

In 2008, legislation was passed that added a form called the “Physician Orders for Life-Sustaining Treatment” (POLST) to the other forms available to Californians for conveying their wishes for end-of-life health care.  The POLST is filled out by the patient and signed by a physician or by a nurse practitioner or physician assistant under the supervision of a physician.  The other forms include the “Advance Health Care Directive” and “Do Not Resuscitate” forms.

The Advance Health Care Directive (AHCD) has replaced the Durable Power of Attorney for Health Care in California as the legally recognized document for appointing a person to make health care decisions on your behalf in the event that you should become incapacitated.  An Advance Health Care Directive permits you not only to appoint an agent, but to give instructions about your own health care.  A free AHCD form can be downloaded at http://ag.ca.gov/consumers/pdf/ProbateCodeAdvancedHealthCareDirectiveForm.pdf .

If you have questions about your current arrangements, you may find answers at https://capolst.org/ .

The POLST form is designed to supplement the AHCD form by allowing you to specify your wishes to your physician about specific decisions regarding your health care.  These decisions might include questions about pain relief medications, intravenous feeding or placement on a machine to help one to breathe.  A POLST form can be downloaded at http://www.mbc.ca.gov/Forms/Licensees/emsa-111b_polst.pdf .

While contemplating our mortality is not intuitively a pleasant exercise, making decisions about our wishes as we exit this life can be a marvelous comfort to the loved ones we leave in charge.  It is mysterious that taking care of such matters often is a consolation even to the person recording their decisions.  Perhaps it broadens our mortal perspective.