Classic cases revisited: Mr Miura and the delusion of immortality

Abstract

Death continues to be viewed as a failure by many clinicians and society. For now however, it remains a biological certainty and to think otherwise is to delude oneself. Nevertheless, the society is becoming older and many individuals enjoy fulfilling life in spite of advancing years. The trajectory of age-related physiological deterioration varies, introducing an uncertainty as to the potential for survival when faced with critical illness. There is risk of harm associated with invasive interventions and utility of such remains uncertain in the very elderly. Changing demographic demands improved triage of the elderly patients and an evolution of the research agenda to acknowledge ageing population. There is also moral imperative to ensure avoidance of harm and cost-effectiveness in relation to intensive care unit utilisation by this patient population.

May God bless and keep you always

May your wishes all come true

May you always do for others

And let others do for you

May you build a ladder to the stars

And climb on every rung

May you stay forever young

Forever young, forever young

May you stay forever young

Bob Dylan

Certainty of death, small chance of success, what are we waiting for?

Dwarf Gimli, Lord of the Rings (Film)

Introduction

Delusion is a belief that is held with strong conviction despite superior evidence to the contrary. ¹ Biology dictates that death of an individual organism is inevitable. To believe in immortality is thus irrational and can be seen as a form of delusion. Yet this particular delusion has accompanied humanity throughout the history of civilisations. The beliefs in life after death, reincarnation, paradise and life-eternal, feature amongst many religions. Now, with society becoming more secular, medicine and medical practitioners need to deal with patients failing to acknowledge their own mortality. Medicine is unlike religion, and rather than being based on beliefs, it is based on facts. Currently, the certainty of our mortality is one such fact. To believe otherwise should be seen as a delusion. This paper explores the difficulties faced by critical care physicians involved in the triage of elderly patients who are critically ill and may be approaching the end of life. The relevance of age with regards to mortality is discussed along with the changing demographics that will lead to greater numbers of elderly being referred to critical care services. The changing demographic is likely to create tension between the utilitarian and deontological approaches to patient care given the limitation of resources. At the same time, patient centred approach, taking into account the “primum non nocere” principle, should prevail. Features of pathological ageing are highlighted offering potential avenues that may facilitate triage of the older patients.

Case report – on top of the World

On 23 May 2013, Yuichiro Miura, then aged 80, became the oldest person to climb Mount Everest. ² It was the third ascent of the highest mountain in the world for the elderly mountaineer, for he has also achieved it aged 70 and 75. His achievement is notable not just because of his age. He had overcome numerous medical problems including diabetes, obesity, renal disease and four episodes of surgical cardiac intervention for disabling arrhythmia, with the last intervention being just months prior to the ascent. In 2009, he suffered complex pelvic and femoral fractures in a skiing incident that was felt would impair his ability to walk. Formerly a school headmaster and in later life a politician, he was, above all, a professional skier made famous by ski descents of Mt Fuji, Mt McKinley and at the age of 36 a ski descent on the slopes of the Mt Everest, which nearly ended in disaster. One could say that his inclination towards phenomenal physical performance rested in his genes. His father, Keizo Miura, a professional skier as well, reportedly skied down Mt Blanc at the age of 99 and held a record for the oldest person to ascent Mt Kilimanjaro at 77. ³ Mr Miura’s adventure met with some criticisms. On the descent, he became so exhausted that he was airlifted from Camp 2 by a helicopter and flown back to Kathmandu, Nepal’s capital. Purists would insist that he has not completed the climb by failing to descend. Also, the entire cost of the climb, including the oxygen, the guiding team, climbing physician and the Sherpa support was approximately ¥150m, which would approximate to nearly one million pounds. ⁴ Mr Miura was delighted at his achievement and rightly so, but the price, one could argue, was extraordinary. The money had literally built a ladder to the stars…

Forever young?

The population of the UK is projected to grow to over 74 million by 2039. It is an increasingly older population with 18% aged over 65 and over and 2.4% aged over 85. By 2039, those 75 or over will constitute nearly 10% of the society and the number of those aged over 85 shall double to reach 3.6 million! ⁵ This shall mean that 1 in 12 citizens of the UK will be aged 80 or over. ⁵ The United Nations report indicates that between 2015 and 2030, the number of people aged over 60 will grow by 56% from 901 million to 1.4 billion, and by 2050, the global population of older people is going to more than double. ⁶ The population of persons over 80 years of age will more than triple comparing with 2015 figures. ⁶ In Europe, the population is getting older with the median age increasing by 8.3 in the last half of century. ⁷ The proportion of individuals over the age of 65 is expected to rise from 16% in 2010 to 29.3% by 2060, and of those over 80 from 4.1% to 11.5%. ⁷ This is reflected in the age of patients admitted to hospital and to intensive care unit (ICU), with records for patients aged 65 or over accounting for 51.6% of all known critical care records in the UK. ⁸ In Mr Miura’s country Japan, famous for the longevity of its citizens, the Japan Times reported that the number of people aged over 90 has exceeded 2 million. ⁹ Older patients are an unavoidable fact of life, and the practice of critical care medicine needs to adapt to the needs of that population, yet, evidence for application of organ support therapies seems rather thin. Even though modern trials do not exclude elderly the mean age in the recent large randomised controlled trials of early goal directed therapy was between 60 and 66.4.^10–12 Pro-active intensive care outreach leading to admission of critically unwell older patients may in fact lead to increased mortality. ¹³ People age in different ways, and not everyone has the prowess of Mr Miura when they reach 80. Pathological aging where clinical syndromes such as frailty and sarcopaenia arise would ultimately impact on outcomes, and this should be acknowledged when designing critical care trials.

Frailty and sarcopaenia

The concept of frailty in the context of critical illness was introduced perhaps by McDermid and others. ¹⁴ Currently, there is no universally approved definition of frailty. It is a syndrome of diminished functional reserves that increases vulnerability to physical stressors and increases the chances of adverse outcomes. A report by the British Geriatrics Society, “Fit for Frailty”, defines frailty as a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves. ¹⁵ Attempts at developing an operational definition of frailty have been made. One such definition views frailty as a clinical syndrome in which three or more of the following criteria were identified: unintentional weight loss, self-reported exhaustion, weakness (grip strength), slow walking speed and low physical activity. ¹⁶ Defined as such, it has been predictive of an increased likelihood of death. Frailty is a term that correlates with physical vulnerability and it has been linked to a descriptive scale by Kenneth Rockwood in 2005. ¹⁷ The scale provides good a descriptive overview of frailty. Frailty syndromes, as they have become known, include cognitive impairment, falls, mobility problems pressure ulcers, incontinence and susceptibility to side-effects of medications. A study exploring the prevalence of frailty syndromes as coded by ICD-10 classification of diseases demonstrated a prevalence of 14% amongst admissions of patients over 65 years of age in 2013 in England. ¹⁸ Their prevalence appears to be increasing. In the context of intensive care, frailty is highly prevalent and present in 30%. It is associated with higher hospital mortality, long term mortality and an increased risk of long term institutionalisation. ¹⁹ The recently presented VIP1 study demonstrated an inverse relationship between severity of frailty based on Rockwood scale and short term survival in patients over the age of 80 admitted to ICU. ²⁰ The underlying mechanisms of frailty are linked to ageing, but in essence arise when physiological homeostatic redundancy present in any organ or tissue has been lost, making it vulnerable to stress. The more different physiological systems are abnormal at baseline, the more likely the organism will succumb to frailty. ²¹ It is important however, to note that frailty is not an inevitable part of the ageing process, and Mr Miura serves here as an example.

The term sarcopaenia has been coined by Irwin Rosenberg in 1988. ²² Initially, it was intended to be applicable to the loss of muscle mass through atrophy associated with ageing, which would be linked to the decrease in strength and function, but with time, the concept evolved. Other causes of muscle atrophy such as malnutrition, disuse or inflammatory states were felt to be distinct in nature, and thus, terminology evolved to acknowledge the distinction between primary or age related sarcopaenia and secondary sarcopaenia. ²³ As with frailty, more than one definition of sarcopaenia exists. However, with muscle mass being more tangible or measurable one hopes a diagnosis allowing risk stratification could be achievable with greater ease. The original definition of sarcopaenia was grounded on the ratio of skeletal muscle mass as determined by dual-energy X-ray absorptiometry over height squared with sarcopaenic individuals having values that were two standard deviations below that of sex-matched health controls. ²⁴ Other definitions exist and have been reviewed by Peterson. ²⁵ It seems promising that imaging modalities such as computed tomography (CT) and ultrasound are increasingly employed in the diagnosis of sarcopaenia. Conceivably, as it is erector spinae, quadratus lumborum and abdominal wall muscles that are analysed in assessment of sarcopaenia, ²⁶ this could be performed every time CT of abdomen and pelvis are performed on ICU patient. Alternatively, for those looking for bedside techniques, ultrasound could be used. ²⁷ Sarcopaenia is present in approximately a quarter of hospitalised patients. ²⁸ It affects not only the elderly. It is highly prevalent in ICU patients with reported rates being 60–70%. ²⁵ It is associated with prolonged duration of mechanical ventilation, infectious complications, prolonged length of hospital stay, the need for post-discharge rehabilitation and greater mortality. ²⁰

Chance of success?

Mr Miura’s case does demonstrate that life can be fullfilling and exciting in the old age in spite of the burden of medical conditions. The elderly can benefit from ICU care, but knowing exactly who will is a challenge. The majority of studies examining outcomes of elderly patients in ICU have been retrospective and thus subject to selection bias. Yet, even if the assumption exists that fit patients are selected for invasive treatments in the existing studies the outcomes are worrying. If admitted with pneumonia to ICU, a patient the age of Mr Miura can expect 30% mortality at 30 days and 57% mortality at one year. ²⁹ Looking at the relationship between critical care admission and age, those in the 75–84 age bracket can expect a 23.5% hospital mortality and a 45.9% one year mortality. ³⁰ Quality of life among survivors remains a question. Age alone should not be a deciding factor in the decision whether to admit a patient to ICU, ³¹ but it is linked to the likelihood of mortality.^29,30 Concepts of sanctity of life and avoidance of harm – where death is seen as ultimate harm, are also deeply ingrained among medical practitioners, which combined with the changing demographics leads to increased numbers of elderly patients being admitted to ICUs. There is however a risk that in spite of good intentions we may harm patients at the end of life. An epidemiological study of in-hospital cardiopulmonary resuscitation (CPR) in patients over 65 years of age, showed a steady incidence of cardiac arrests over the years, but a trend towards increased mortality. ³² The authors were concerned that the findings suggest that the frequency of administration of CPR to the patients that are not going to benefit from it, is increasing. Extrapolating from the finding that nursing facility residents had worse outcomes the authors felt that chronic illness impacts on survival, and one could surmise that frailty does so too. Another study to suggest possible harm of critical care interventions in the elderly is the recently published ICE-CUB 2 study, which is a prospective cluster randomised control trial of 3037 critically ill patients aged 75 years or older. ¹³ The intervention group had a systematic ICU led triage on admission to hospital. The patients were randomised in the emergency department, and inclusion criteria required them to be cancer free and to have preserved functional status. Patients in the study had a median age of 85. The patients in the intervention group had increased ICU admission rates compared with standard practice (61% vs. 34%), yet their risk of death at six months was increased (45% vs. 39%). Adjustment for baseline characteristics has ameliorated that effect, but ICU admission still appeared to be of no benefit. ¹³

A question – ‘would you like to be resuscitated?’ – is a wrong question, if one feels the outcome would not be successful. Exploring with the patient and the family what admission to ICU involves and the possible outcomes might be a better route, ³³ especially given the existing outcome data. This might be particularly so, in view of changing attitudes towards consent in the aftermath of the Montgomery case, ³⁴ although admittedly, many patients would not have the capacity at the time of the admission. The life the patient thinks of, gained as a result of ‘resuscitation’, is the return home, the return to function and quality of life they have enjoyed so far. They assume that the promise to ‘resuscitate’ includes that. Lifespan in terms of chronology of survival is not the same as health-span, but as medicine evolves with the elderly in mind, perhaps longevity will be accompanied by gains in terms of the health-span. For now, our craving for immortality fails to acknowledge accompanying health or lack of it.

The quest for immortality

There is no doubt that the promise of science borne out in technology is advancing at a great pace. When Jules Verne, a popular science fiction writer of the 19th century, imagined submarines and space rockets, those were still in the realm of fantasy. Modern science fiction writers look towards a world beyond death and mortality. For now, such thoughts remain mere fiction, yet the society is readying for such a leap. In 2016, one of the presidential candidates in the United States of America was Zoltan Istvan, a journalist, a futurist, an enterpreneur, but above all a transhumanist. Transhumanism is an intellectual movement that seeks to harness evolving technology to enhance human condition and, in particular, human intellect. The idea of transhumanism is guided by a perfectionist imperative that drives directed evolution by technological means. Some see the ultimate goal of such a process as immortality achieved through the interface of human body with the technological substrate. Mr Istvan’s stated goal, as a presidential candidate, was ‘overcoming human death and ageing within 15-20 years’. ³⁵ In the UK, a bow in that direction came from an unexpected quarter. On 6 October 2016 Mr Justice Peter Jackson, high Court Judge passed a verdict that permitted cryopreservation of the body of a 14 year-old girl dying of terminal cancer, acknowledging her belief in the potential of futuristic interventions.^36,37 The girl writing to the judge stated that ‘being cryopreserved gives me a chance to be cured and woken up - even in hundreds of years’ time’. ³⁷ Sadly, it was parental conflict that brought the case before the courts and the judge was reported to have made a decision adjudicating in the face of that conflict rather than deciding on the rights or wrongs of cryogenics – which is a transhumanist movement. The Judge commented that the case was an example of science giving rise to new questions for the law. The author is not aware of a case of a transhumanist demanding life sustaining interventions in the face of death.

Conclusions

Death continues to be viewed as a failure by many clinicians, and society. For now however, it remains a biological certainty and to think otherwise is to delude oneself. As we get older, the time of death approaches, but the trajectory of age-related physiological deterioration varies, introducing an uncertainty as to the potential for survival. The case of Mr Miura serves to remind us that age alone is not a bar to physical prowess and alone should not be the determining factor in assessing for suitability for critical care admission. At the same time, Mr Miura’s physical prowess stands in contrast to the frailty encountered in many of the elderly patients admitted to the hospital. Given the demographic trends we, as critical care clinicians, shall increasingly face decisions about the suitability of elderly patients for invasive interventions. There is potential for harm associated with such interventions, and utility of such interventions is also limited. The association of frailty syndromes, with sarcopaenia as a measurable aspect of frailty, with poor outcomes offers a potential triage tool that should find use in the selection of patients that may benefit from ICU care. The current high prevalence of frailty in ICU suggests the likelihood of poor patient selection. The value of survival alone is subjective and needs discussion with individual, in terms of consent, and at societal level given the limitation of resources. Survival alone is not equivalent to restoration of health, which is the patient-centred goal. There is also perhaps a need for a change in the ICU research agenda. Older patients may face different odds when admitted to ICU, and the risk of harm may outweigh benefits in terms of quality of survival. Are the interventions on offer thus appropriate? Such research should include an economic evaluation of treatments offered vs. benefit gained.

Epilogue

Mr Miura was not the only climber of advanced years to climb on the slopes of Mt Everest. His main rival for the title of the oldest man to summit the mountain was a Nepali man, Mr Badur Sherchan. Aged 85, he embarked on a journey to reclaim his title of the oldest man to summit from Yuichiro Miura. He died at Everest Base Camp. ³⁸ The cause of death was not stated, but presumably was old age.