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When Tithonus met corona: the COVID-19 pandemic and acute illness in the elderly
  1. Yasir Al-Rawi
  1. Dept. of Elderly Medicine, Hampshire Hospitals NHS Foundation Trust, Basingstoke RG24 9NA, UK
  1. Correspondence to Dr Yasir Al-Rawi, Elderly Medicine, Hampshire Hospitals NHS Foundation Trust, Basingstoke RG24 9NA, UK; yasir.al-rawi{at}hhft.nhs.uk

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“Who wants to live forever?”

Fredie Mercury, 1946-1991

A difficult question but one pondered over by philosophers at various points in history. Medicine in the last half century has done more to advance this proposition than ever before. We open hearts and brains, transplant lungs and kidneys and kill cancers with ever greater precision and accuracy. Yet despite all that, can we achieve immortality? Not really.

We have achieved what Neil Skolnik aptly termed a ‘Tithonus syndrome’.1 In Greek mythology Tithonus was a Trojan prince who caught the eye of Eos, the goddess of dawn. She abducts him and asks her father Zeus, king of the gods, to grant him immortality—but forgets to request eternal youth. The consequence is handsome Tithonus continues to get old without ever dying.

People increasingly live to old age for many reasons including improved social standards, better access to medical care, higher education levels and population wide preventative measures for conditions like infectious diseases, cardiovascular disease and cancer. Although we have longer healthier lives a proportion reach old age after various procedures and medical interventions in middle age such as bypasses, stents, —ectomies, transplants and a lot of potent medication. Thus, the population is ageing not because it is healthy, eating well and has ‘good genes’ but rather from a lot more medical attention. As a consequence, morbidity, rather than ‘compressed’ in older age, is more spread out. It is this older, multimorbid group that is increasingly seen in hospitals and by healthcare professionals.

Gruenberg called this the ‘Failure of Success’, where success in preventing death leads to more prevalent morbidity and chronic illness.2 Is there an alternative ? No. Ethically and morally we are bound not just as a profession but as a society to save, extend and improve life. However, should this be done at any cost? Do we wish to achieve immortality—but become frailer and more infirm in the process? Do we want to be Tithonus?

Medicine and society as a whole recognise there is no such thing as immortality. There is certainly no eternal youth yet both shy away from this fact at critical junctures. When faced with treatment options with different outcomes both surrogates and attending medical practitioners would choose differently compared with what they would recommend for a patient.3 4 Generally, both choose or recommend the option that preserves life—but would not necessarily make the same choice for themselves. Thus, in normal times we find medical decision-making favours more investigation, active treatment and intervention in the acutely unwell frail elderly.

However, what the present COVID-19 pandemic has shown us is that scarce resources need to be judiciously allocated. One factor being used to do this (especially for higher level care and intensive medicine) is age.5 6 Previously, we avoided this as a discriminatory measure for where treatment levels and ceilings should be set and relied on projected ‘quality of life’. In the current pandemic we have recalculated. In the recent past, we would continue treatment and investigation but now have re-calibrated our comfort/confidence zones to a more practical pragmatic utilitarian dimension.

It is no surprise age acquires such importance in clinical decision making. The body changes in myriad ways, impossible within the scope of this article to review, but the changes affect all organs and aspects of homeostasis. The net result resembles an organised involution and biologic implosion in preparation for the inevitable.

Death is a certainty in life. The only two permutations are dying in old age or before it. Although we continue to desperately try and prevent the latter we are now more accepting of nature’s ability to effect the former. Society in the time of COVID-19 is less keen to perpetuate a Tithonus Syndrome and more willing to embrace a different approach to the medical care of the frail elderly. A concept that focuses on the priorities of life rather than simply trying to ward off death.

Physicians have taken on this task with a willingness that is not without trepidation and a sense of apprehension about its moral and ethical dimensions. It is always difficult in medicine to strike a balance between realism and nihilism. What this pandemic has taught us is a healthy dose of realism does not mean abandoning the old or making them more disadvantaged. On the contrary, we must ensure care is not compromised in the unavailing quest for a longer life. As physicians our first priority is to preserve life but if we cannot do that, then improve what is left. But if we cannot even do that then we must ensure life does not get worse, especially by our actions. To quote Sir Robert Hutchison, the eminent early 20th century physician ‘…from making the cure of the disease more grievous than the Endurance of the same, Good Lord, deliver us’.

It remains to be seen whether in a post-COVID-19 world we will return to our pursuit of immortality—and Tithonus is resurrected.

Acknowledgments

I would like to thank my colleague, Dr. James Kelly, for his comments on prior versions of this manuscript. The ideas and opinions expressed herein are those of the author’s alone, and endorsement by the author’s institutions is not intended and should not be inferred.

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Footnotes

  • Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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