Pneumonia, "the old man's friend"?

April 5, 2020 3:34 PM

Prior to coronavirus, I read about the unwisdom of giving the very aged the pneumonia vaccine because pneumonia was a far preferable way to die than many other common causes. Sir William Osler referred to pneumonia as "the old man's friend" because "taken off by it in an acute, not often painful illness, the old man escapes those 'cold gradations of decay' so distressing to himself and his friends." Pneumonia would often let you slip away in your sleep, etc. But all of the descriptions of pneumonia caused by coronavirus use phrases like "feeling like you are drowning," "suffocating to death," etc. Can you help me understand?
posted by HotToddy to Health & Fitness (16 answers total)

I'm not a doctor, not a medical person, but my understanding would be that, if you are in a hospital and have gotten to that point, and you're lucky enough to get good care, they'd have sedated you a lot by that point. At home, I don't know.
posted by DMelanogaster at 3:39 PM on April 5, 2020 [1 favorite]

Sometimes in really elderly people a infection like pneumonia doesn't trigger a big immune response like high fevers and distress, and instead they simply gets more lethargic, which I guess can be seen as a peaceful to pass. This is not guaranteed though and seems a poor reason not to get a vaccine.
posted by Pantalaimon at 4:24 PM on April 5, 2020 [4 favorites]

Or maybe it's "the old man's relatives' friend" which as described may be a a less traumatic way for people to watch the ones they love die.
posted by Max Power at 4:33 PM on April 5, 2020 [17 favorites]

Well one thing about covid19 is that you can get to 75% oxygen saturation without really feeling that bad. Normal is 95%, maybe 90% at high altitudes. Normally 84% is low enough for people to be crazy desperate for air.

I've read several accounts in older books that pneumonia is like a slow drowning, but that people are super out of it from fever and they die fairly quickly.

Probably better than dying of many afflictions in the past like stomach cancer, kidney stones, pox, or battle wounds. I suppose it's all relative.
posted by ananci at 4:38 PM on April 5, 2020 [5 favorites]

Disclaimer: I'm 7 years out of the ICU, and I haven't been pulled back in yet, but from what I can tell, the following:
What is being described medically is less pneumonia itself and more the ARDS (acute respiratory distress syndrome). ARDS is massive inflammatory state which focuses in the lung, leading to fluid where it shouldn't be, and this leading to severe problems with oxygen getting into the blood (since the lung is where that happens.) Protein-containing body fluids (blood, components of blood) leak into the parts of the lung that aren't supposed to have fluid. This in turn causes more inflammation, making lung tissue more easily injured, leading to fluid in more places...and so on. Severe pneumonia can cause ARDS but you can actually have ARDS without a pneumonia.

ARDS is a terrible thing and we don't have great ways of treating it, even in the ICU. The physics of the lung and of air make it tricky to get air in to all the distant tiny branches of the lungs, where it really needs to go, without causing more injury and this has led to a lot of tricks with things like literally flipping people ('prone/proning') to get the response and using antiinflammatory drugs.

So as per Pantalaimon and internet fraud detective squad, station number 9, this isn't standard winter pneumonia, with the elderly building a weaker immune response and plenty of old school opioids used by bedside MDs. People were never alive to be this sick in Osler's day.
posted by cobaltnine at 5:24 PM on April 5, 2020 [23 favorites]

All I know is when I had pneumonia several years back (and was hospitalized for it, nearly put on a ventilator), it was incredibly traumatic. I couldn't breathe, I was cognizant of that fact, it felt like an elephant was sitting on my chest, and I would often be gasping for air. I think anyone who says that any pneumonia is a "preferable way to die" is just wrong, never mind that it's ARDS that gets you with Covid-19.
posted by cooker girl at 6:15 PM on April 5, 2020 [4 favorites]

Yeah, Old Man drifting in and out of consciousness until the point of not waking up that last time vs screaming in pain until the bitter end because your spleen just exploded or you had your arm chopped off. Mindset. Old will probably be more likely to have that "better to go without screaming pain".

Yes I've also been in the ICU and told that I would be dead within a couple of days. I got better. At least it wasn't constant pain.
posted by zengargoyle at 6:39 PM on April 5, 2020 [1 favorite]

I just wanted to chime in about my understanding of the thoughts behind this phrase, as it has always brought up fruitful discussions amongst colleagues.

Take this with a grain of salt from a third year psychiatry resident but I have heard this phrase many times, particularly during my neurology and internal medicine months.

The context I’ve heard it in has been as a way to demonstrate the concept of quality of life vs quantity of life.

We as a society (and really, most societies, religions, cultures) tend to value the primacy of life as the ultimate goal.
But modern medical science has advanced to a point where we can keep people going past the point at which they, in the not too distant past, would have died of natural causes.

The question is (setting aside the current covid situation,) maybe we CAN someone on a vent, maybe we CAN keep giving people more and more surgeries and more and more medicine, but SHOULD we?

Certain medical interventions can prolong life but the side effects might leave you more infirmed in the process, and all of this is done in the name of extending your time - for ex this scenario comes up a LOT with elderly patients who may not be able to give consent for some reason, but have never discussed their wishes regarding DNR/DNI with their families, who are loathe to make any choices that are perceived as life shortening. Their lives might be extended for a few months but the quality of that life might be limited by pain or suffering.

Perhaps in such a scenario, a disease that could help you pass relatively easily and without much suffering is the preferable option (like the pneumonia Osler talks about, vs the suffocating/drowning that is likely secondary to ARDS in covid, as mentioned above.)

Obviously there are no hard and fast answers here. We value life, and in the absence of explicitly stated (and documented) wishes, physicians and health care workers are obliged to extend it, generally speaking. (Also - this is why discussing in advance DNR/DNI statuses, medical power of attorney, living will, etc with loved ones is super important.)
posted by Eudaimonia at 11:32 PM on April 5, 2020 [7 favorites]

When Osler was practicing, a 60 year old was an old man.
posted by chiquitita at 3:40 AM on April 6, 2020 [1 favorite]

Can you clarify where you read about not giving the pneumonia vaccine? It wasn't from Osler, who died in 1919 (ironically, of pneumonia brought on by the influenza pandemic).

Also, cobaltnine is right that our medical fear with covid isn't so much pneumonia as ARDS (and the stealth myocarditis that is killing people days after apparent recovery from ARDS). ARDS is a challenge to treat in the best of times when you might have a couple ARDS patients in a unit and plenty of resources to devote to them. Thousands and thousands of patients with ARDS, all at once, is ... nightmarish.
posted by basalganglia at 4:32 AM on April 6, 2020 [2 favorites]

The journalist Malcolm Muggeridge describes how, when he was writing the Diary column of the Evening Standard in the 1930s, he would occasionally be given a paragraph handed down from the proprietor, Lord Beaverbrook, with instructions that it 'must' be included:

Another 'must' paragraph entrusted to me was to point out that the bronchial complaint of which Sir James Barrie was reported to be dying, was known as 'old man's friend' because it was so painless. Again, the reason was clear: Beaverbrook, an asthmatic, expected to die of a similar complaint, and wanted to be reassured that it made for an easy death by reading it in the Diary. Harley Street was unresponsive when asked to provide confirmation, but the Diary nonetheless made the point, and kept its little old reader happy.

That said, my understanding is that if you're elderly, pneumonia can put a strain on your heart which carries you off quite easily. (I had a relative who died of this, aged 90, and it was an enviable death.) But in that case it's the heart that kills you, not the pneumonia.
posted by verstegan at 6:08 AM on April 6, 2020 [2 favorites]

My suspicion is the the contrast was to dying of cancer which often involved an extended period of harsh treatments and pain. Cancer treatment is a lot better now, so I think it's not so common, but still not unknown.
posted by SemiSalt at 6:33 AM on April 6, 2020

Response by poster: basalganglia, no, it wasn’t Osler, it was some physician from the current day commenting in some article, I think about routine interventions that prolong life and whether we’re ultimately doing more harm than good. I’m pretty sure he was talking about being notified by his mother’s nursing home that they were giving her the vaccine and he was like, what? No! But I have no idea what specifically I was reading, sorry.
posted by HotToddy at 6:53 AM on April 6, 2020

This does not directly answer your question but I believe it was fairly common (or at least not uncommon) to administer high doses of opiates or similar to hasten death in those who are elderly, in pain and hours or days away from death. I would not be surprised if pneumonia was a pseudonym in some cases for euthanasia. For example, QE2’s grandfather (?) died in a cocaine/heroin overdose allegedly so his death would be written up in the more respectable morning paper. Ironically his doctor later argued against euthanasia. I believe the concept of euthanasia is seen differently amongst the elderly or those soon to pass. The modern day equivalent of taking someone off life support.
posted by geoff. at 11:33 AM on April 6, 2020

One of my very first diagnoses in a patient was pneumococcal pneumonia which had been misdiagnosed as gastro. The bloke was elderly, on nasal prong oxygen, but perfectly able to eat, toilet, chat with family. Treatment was a few days of IV antibiotics and then home for another ten years perhaps of good life. I feel antibiotics are almost always worth a try. On the other hand I've also seen severe both sided pneumonia that did not respond to antibiotics in very elderly patients with health problems, and in that case ceasing antibiotics and comfort measures did seem to lead to a fairly painless death.
I give a lot of pneumococcal vaccinations, both kids and elderly.
I think that pneumococcal pneumonia would be quite different to ARDS in COVID; if nothing else there's an element of fear and worry about spreading it to others.
posted by quercus23 at 3:03 PM on April 6, 2020

I read an article about this too recently--it might be the same one. It was from The Atlantic, October 2014. "Why I Hope to Die at 75," by Ezekiel J. Emanuel.
posted by bruschetta_cat at 6:18 PM on April 6, 2020