
Winter has Arrived in Game of Thrones and America
Over the past few weeks, the world has once again been swept by the hit HBO series, Game of Thrones. The first episode of Season 7 set records for viewership with over 16 million watchers, a 50% increase since last season. The engaging plot that has been the undercurrent for the show has been The Wall, a massive fortification that protects the living from mythical creatures who resurrect the dead, the White Walkers. Upon their presence, snow and ice change the natural environment leading to a slogan that the House of Stark has made their motto: “Winter is Coming,” to always remember to be prepared for the White Walkers.
Ironically, this plot line can be applied to American demographics as the baby boomer generation grows older with increasing morbidity and mortality expected in the next twenty years. The costs of this transition will be tremendous for personal wealth and the healthcare system. As with the rest of landholders in Game of Thrones, called the Seven Kingdoms, the idea of an invading army of death seems to more mythical then realistic. To acknowledge that there may be a bigger problem for American society would mean putting aside the daily individual struggle for success which proves to be the norm for Game of Throne characters and Americans alike. Fortunately, or unfortunately, this denial will be forced to end as US healthcare reform is currently the central debate and the show only has two more seasons to conclude the Great War of Living vs Dying.
As a palliative care physician, I am forced to to see that dying is a reality for all of my patients. The timeline is unclear but the cool air of cancer, chronic obstructive pulmonary disease, congestive heart failure and similar conditions has entered with knowledge that the final seasons of life has arrived. Each individual has a different spectrum of acknowledgement with the range of full denial to preparation via identifying quality indicators of what makes life meaningful and worth living. Those patients who complete the latter tasks seem to gain insight with better outcomes thus one of the goals of palliative care.
The idea of a wall or ‘defense’ against the concept of dying is not a new one. Sigmund Freud and his daughter Anna first proposed such defenses in the early 1900s. The concept is initiated from the idea that all of us have anxieties or issues that are too stressful or uncomfortable to recognize in our conscious. If they were allowed in this space, we would feel overwhelmed and threatened with no ability to cope around daily activities. The human psyche or ‘ego’ developed a set of defense mechanisms to ward off unpleasant feelings and keep them in the unconscious. This wall, however, can only keep them at bay as unconscious drives can still exert effects on conscious actions. Examples of defense mechanisms include displacement in which a person maybe angry with their doctor but instead of yelling at him/her they scream at their dog. One of the tenets of psychoanalysis was to allow patients to work through these unconscious anxieties. This practice of psychotherapy takes years of effort and engagement which is not practical for the majority of Americans especially those with life limiting illnesses.
I believe another route around the wall of defenses thereby allowing individuals deal with their concerns around mortality is social media. The average American will spend two hours a day on social media sharing, gathering and exchanging information. It is a venue that has elements of reality and aspects of fantasy likely driven by our unconscious. This can be on full display when people post things they would not or could not say in real life. Can patients utilize this virtual arena to talk about the unmentionables of life: getting older, getting sick and dying? Is social media the missing key to facilitate dialogue on these important issues? Do healthcare providers need to pay more attention on how individuals are engaging online?
I believe the answer to all of these questions is yes. As we enter the next stage of the healthcare revolution, answers will need to come from outside of the system. Winter is coming for many of us and without a dialogue to prepare for it, the kingdom will be lost.
