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Predictions for end of life care

I was born and raised in America by Chinese parents, so I’m no stranger to cultural conflict. Why do we take our shoes off in the house? Why do people at school think our food is weird? Why should I study extra if people make fun of me for it? Chinese values would constantly butt heads with the American values of my peers.

Given the option, I preferred traditions that didn’t make me feel like an outsider.

I wavered on most issues growing up (and still do), but there was one value that got buried deep inside of me: filial piety--the virtue of respect for ones parents and ancestors. My life’s goals would change from year to year, but enabling a joyful life for my parents (particularly in old age) was always one of them. People my age that were raised by immigrant parents tend to share this conviction.

The core conflict in the pursuit of this goal is the Chinese cultural tradition of familial cohabitation. As parents grow older, we expect them to move in with one of their children and experience end of life surrounded and supported by family. This tradition is one of the reasons nursing homes are popular in Western cultures but rarely seen in Eastern ones.

This isn’t yet a problem for me--my parents are awesome and healthy and young--so I haven’t given this too much thought. I’ll make the decision later and whether it’s a retirement community or living with me, whatever decision I make will maximize the joy my parents experience.

Now I’m starting to think that it’s not so simple. I’m reading Atul Gawande’s Being Mortal and his inspection of our current relationship with end of life helped me realize two things. First, we’re squeamish about death, so we don’t think that much about end-of-life care or the macro trends we’ll have to face. Second, these trends lead to new and unresolved problems related to end-of-life and these problems affect my ability to maximize the joy my parents experience as they age.

The most important macro trend is the shift in the demographic makeup of our communities. In the past, we had a large base layer of young people. The mortality rate was much higher, people lived shorter lives, and we had more babies. This led to a pyramid shape.

Demographic Shifts

Today, we’re more like a rectangle. We’re living longer, having fewer children, and dying less frequently. And we need only look at Japan to see a possible vision of the future. Vanishingly low mortality rates and a continued decline in childbirth. Our demographic makeup will trend towards an inverted pyramid.

This makes it impossible for the younger generation to care of the elderly how we have in the past.

As a son, there are two problems to resolve. The first is cultural and gets resolved through conversations across generations. The second is the physical reality of independent living. This is the lever I’m interested in and I think it’s the biggest opportunity to improve the experience of the elderly. Of course, my first thoughts are about technology.

The natural question: how can we use technology to enable and extend independent living?

Gawande cites a useful framework in his book called the eight activities of daily living.

  1. Feeding
  2. Toileting
  3. Selecting proper attire
  4. Grooming
  5. Maintaining continence
  6. Putting on clothes
  7. Bathing
  8. Walking and transferring

I’d never heard of them before, so I did a little Googling and found an additional seven instrumental activities of daily living.

  1. Managing finances
  2. Handling transportation
  3. Shopping
  4. Preparing meals
  5. Using the telephone and other communication devices
  6. Managing medications
  7. Housework and basic home maintenance

These are called ADLs and IADLs, and together offer fifteen core problems that the elderly need solved. The problem space is complex and this is the first I’ve really thought about it, but here are some general thoughts.

NOTE: These are solutions for an elderly population with money to spend. There are grave challenges ahead for the elderly population with no money, but that’s outside the scope of this thought experiment.

First, services that power the shut-in economy (the phenomenon of young people having all of their basic needs met by apps) are really more useful for the elderly. Feeding and preparing meals is easy with DoorDash, BlueApron, and Munchery. Selecting proper attire can be helped by TrunkClub and virtual style consultants. Uber solves travel. Software that actively manages finance (the Wealthfront model) can help with finances. Amazon handles shopping. Homejoy and Taskrabbit resolve any household problems. A subscription service could deliver the perfect mix of medications every day.

As long as you can operate a mobile device with these apps, you can alleviate the burden of half of these activities. The remaining problems arise at later stages of mental or physical deterioration. Thus, our focus is on either the prevention or several of this deterioration (depending on the stage).

Demand for products and services that slow mental and physical deterioration will grow dramatically. In other words, “healthy” lifestyle brands targeting the elderly will thrive just as healthy lifestyle brands have captured the minds and wallets of the young affluent. The concept of a Whole Foods was laughable when I was a kid. Now my friends use Sprig to get healthy food delivered, exercise every other day with Class Pass, learn stuff through online courses, and meditate with Headspace.

Some of these products will work, and thus extend an aging individual’s independence.

At advanced ages, we’ll look for ways to reverse aging. This might come from advances in microbiology, artificial intelligence, robotics, or some other form of human augmentation, but there’s no question we’ll see dramatic advances in our lifetimes. I’ll leave it at that, because I’m not knowledgeable enough here to comment further.

We will reject end-of-life care services that treat people like patients. If technology can extend how long a person can operate independently, then we could expect a corresponding decrease in how long a person spends dependent on others. Today, we focus on keeping people alive, but in the future, we will place more emphasis on the quality of one’s death. Instead of treating death’s approach as a chronic illness that needs to be battled until the last breath on a hospital bed, we will treat it as a celebration of a cherished life.

There are some interesting studies about administering psychedelics to people nearing death. They report an overall sense of well-being and connectedness. A feeling of peace. More acceptance of their death.

What role does virtual reality have to play here? What about social networking? If we lived our lives online, will we want to remember our lives online?

For the entrepreneur, consider this. Building startups for women wasn’t popular a decade ago because we didn’t have woman founders. This was insane because 50% of potential customers are female. Today, building startups for the elderly isn’t popular because most founders are in their late twenties. Given how the demos are shifting, there’s a lot of opportunity to seize.

More importantly, by enabling ADLs and IADLs, we extend how long a person can live independently, and reduce the period of time that we might consider “end-of-life” today. I want to live in a world where we don’t feel a sense of loss as we get older. Not only should we continue to feel agency and independence, we should feel comfortable approaching the end of our lives, knowing that when it comes, we’ll have the services to ensure it’s a dignified, celebrated experience.

Thanks to David Cheng for reading an early draft of this essay

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