By Kenneth Ring, Ph.D.
If you read books or listen to podcasts on spirituality, you are bound to be told – many times ad infinitum – that “we are spiritual beings having a human experience.” I usually wince with dismay when I hear such twaddle repeated over and over. Not that it’s in the category of a Trumpian “big lie,” which is obviously a big lie in its own wrong; I actually believe that I am an eternal being who has dipped into the illusion of time in order to learn certain lessons, such as being able to tie one’s shoelaces without assistance, until I can be sprung from this temporal prison. It’s just that I have a pedant’s revulsion whenever I encounter such pap. It’s the same category as another spiritual bromide, such as “there are no accidents.” You’ve heard that one, too, right? To which I am wont to counter, “except for chance events, errors, mistakes and random mayhem.” Yes, I admit it: I am an unrepentant curmudgeon when it comes to spiritual clichés.
However much such spiritual drivel may arouse my spleen, I have always been a sucker for a good quip or a witty zinger. One of my favorite characters who is as quick with a quip as anyone I know is my fellow curmudgeon, Woody Allen
. Yes, I know his reputation has been tarnished in recent years from all the to-do about whether he did or didn’t, but I have always been partial to Woody, not only for his mordant wit, but perhaps because we are virtual contemporaries, he having arrived on the planet just twelve days ahead of me, in 1935. You will see where I am going with this shortly, but for now “here are some of my favorite things” that Woody has uttered to amuse us:
Nature and I are two.
Man can’t live on bread alone; he also needs a beverage.
I don’t believe in the afterlife, although I am bringing a change in underwear.
But what will be of more interest to us in what follows is suggested by some of Woody’s quips about death. For instance:
I am not afraid of death, I just don’t want to be there when it happens.
There are worse things in life than death. Have you ever spent an evening with an insurance salesman?
I don’t want to achieve immortality through my work. I want to achieve it through not dying.
Clearly, Woody is not keen on death. He says that he is firmly “against it.” Most people would doubtless agree and would rather not think about it. If you are under sixty, you probably would rather think about other things, such as orgiastic sex. In which case, you might not want to bother reading the rest of this blog.
But we are actually not going to talk about death so much as what happens when you get old and have to face the prospect of death. This is when your telomeres begin to shorten, when you start developing tumors or cancer or heart disease, when your body has begun to betray you and you live in fear and chronic, often severe, pain. In other words, we are talking about your future, and mine. We are talking about the disease from which none of us will recover – aging.
I’m afraid this will make for rather grim reading – until the end. And there won’t be much more humor to leaven the load. But there will still be the occasional zinger, as in this famous remark of Bette Davis: “Old age is no place for sissies.” If you live long enough, though, you will be living in that place. Let’s check it out before we get there.
Our guide will be the gifted writer and physician, Atul Gawande
, the author of the best-seller of a few years back, Being Mortal
. In what follows, I will be drawing on his very readable and enlightening book about what’s it’s like to be facing death in America at this time. What he has to tell us won’t reassure Woody, but it will help us be better prepared for the inevitable.
For years I resisted reading this book, despite its excellent reviews and the urging of my cousin, Cliff, a retired cardiologist, who assured me it was a “terrific” book. But having spent forty years consorting with the once nearly dead who had reported their NDEs to me, I figured I had already devoted enough of my life thinking and writing about about death. But, truth to tell, I was just like everyone else when it came to thinking about dying itself. Frankly, I would rather not – die. Or even think about what my later years might entail if I ever should find myself heading toward that final abyss. After all, despite my infirmities and decrepitude, I am actually in pretty good health. I had never had a serious disease, I was still enjoying life and had continued to write and keep as active mentally as I could. I had been extremely lucky, especially compared to many of my friends who were far worse off than I was or who had already kicked the bucket. What me, worry?
But like many elderly people nowadays, I live alone, and as I am now heading toward 87, I had to admit that I could no longer pretend that I was invulnerable to what are often loosely and playfully called “the ravages of age.” Indeed, no male member of my immediate family had ever lived to 87. How long could I really expect my good luck streak to continue? Most oldsters like to think they will die peacefully in their sleep after a happy life. But, face it, that is as rare as winning the lottery, a delusional wish-fulfillment. You may not die like Tolstoy’s fictional character, Ivan Illich, by screaming in agony for three days before your death, but if you were to read Gawande’s book of horrors, you would quickly learn that you are not likely to enjoy your descent toward death once your body begins to fall apart, as it will.
So, in the end, I figuratively girded my loins, and delved into Gawande’s book. In fact, I was already familiar with Gawande. I’d been reading his work for years, mostly in The New Yorker, for which he’s long been a staff writer. But as a writer and medical scholar, he has had a very distinguished career. He has been awarded many literary prizes, is a MacArthur Fellow, and is on the faculty of Harvard. He is widely and deservedly recognized as one of the most outstanding writer/physicians in America. So I knew I would learn a lot from this man.
Still, he begins his book by covering a lot of the ground I have discussed in some of my previous blogs. For example, although Gawande grew up in America, he refers to his Indian background where typically older people are revered and remain in their families until their death. His parental grandfather, for example, lived until almost the age of 110, and only died because of a freak accident.
In cultures with traditional extended family structures, old people are not warehoused into nursing homes as they tend to be in our modern culture. But with the rise of isolated nuclear families in our own time, many old people are effectively deposited into nursing homes where strangers care for them and family members may visit only occasionally, if at all. Or, since increasingly old people, especially women, live by themselves, they may become ill, which creates still other problems. One way or another, the situation of old people can often be fraught with risk or even greater peril – complete abandonment.
But here’s what makes it worse, as Gawande points out. In former times, people didn’t live to a great age. During ancient Roman times, for example, the average life expectancy was about thirty years. Even in the Middle Ages, it was rare to live beyond one’s fifties. And when people did die, they tended to die quickly. Even in George Washington’s time, dying could come overnight, as it did for him. On December 13th, 1799, he suddenly became ill. By the next night, he was gone.
Being interested in classical music, I can’t help thinking of all those famous composers that never made it out of their thirties. Schubert, for instance, died at 31, and Mozart, Mendelssohn, Chopin, Carl Maria von Weber, and Henry Purcell never lived to see forty.
But now, thanks to advances in sanitation, diet, and medical technology, people can live to very advanced ages, which means that, relatively suddenly, our country and most others in the developed world, are struggling to support vast numbers of older people who can no longer live independently. Enormous amounts of money have to be expended, especially in the last year of elderly people’s lives, to house and take care of them. They become, as sociologists put it, “surplus populations.” And since most families can no longer take care of their own, institutions arise to warehouse the old until they die. Thus, we have seen the rise, especially since the middle of the last century, of the obscenity of nursing homes.
Of course, there are many caring people who work in such places, but these are poorly paid jobs, and for many, it is “just a job.” How many of us dream that one day we will wind up in such a dismal and depressing setting, being taken care of by a succession of strangers, when we have lost all agency over our own fate? But this could indeed be your fate one day, my friends. This is how your life could end when you are sick, infirm and perhaps demented. It could happen to me, too, of course, but I would be tempted to say, “over my dead body!” Truly, I would rather die than to end up in such a place, wouldn’t you?
Gawande spends a lot of time talking about life in nursing homes
, and offers a number of case histories of people who were forced to live out their lives there. They make for frightening reading. And, remember, Gawande was visiting such places and writing about them before COVID
hit. We all remember in the beginning of the pandemic that nursing homes were often settings where COVID could easily spread, causing many people to die, perhaps a blessing in a way, though dying of COVID, alone and without family, had to be a ghastly way to expire.
Have you ever visited such “homes?” I have. During the last years of my mother’s life when I was still teaching at the University of Connecticut, I had to place my mother, then in her early 80s, in such a home in Berkeley. I would visit her as often as I could, and once I was able to move back to California, I was able to visit almost weekly until she died.
I am an only child from a very small family, and in all the years she lived there – she died when she was nearly 89 – no one else ever visited her. (Sometimes, however, my girlfriend at the time, would accompany me.) What you would have seen if you had been with me is fairly typical of such homes. You enter and you see a long corridor of people strapped into their wheelchairs, drooling or cursing of just sitting there, mute and absent. Many are demented, of course. My mother shared a room with a succession of women she didn’t know, some of whom would rave during the night, she told me.
My mother was beginning to lose her hearing, but she was still, until the near the end, mentally competent. She could no longer walk, so on nice days I would push her wheelchair around the neighborhood (fortunately, the streets were flat), or take her out in back and read to her (she liked to listen to short stories by Chekhov) or play gin rummy with her. But she couldn’t read, didn’t want to listen to the radio or watch TV. She didn’t even like to be touched. She mostly remained quiet and just stayed in her bed. She had no life. The place had no life. My mother wasn’t mistreated. The staff, so far as I could tell, were kind and caring people. But, still, I felt absolutely dreadful every time I had to leave, seeing her there in her bed, lying passively, not even able to say or wave goodbye. I would kiss her on her forehead and say I would see her again next time until there was no next time.
Gawande, who in preparation for writing his book, spent a great deal of time in places like those in which my mother vegetated and died, came away with the direct knowledge of how much such institutions fail to serve the needs of the people in their care. At the outset of his book, he offers an almost savage indictment of the failures of modern medicine:
You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions – nursing homes and intensive care units – where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the most basic comforts they need most. Lacking a coherent view of how people might live successfully all the way to the very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.
But in his travels, Gawande didn’t just wander through the often soulless and depressing interiors of nursing homes; he also spent a lot of time seeking out experts in the field of death and dying, such as elderly geriatricians (apparently themselves a dying breed), but especially innovators who are trying to change the culture of such institutions so that they would become much more than joyless prisons for people who were suffering and merely marking time, as my mother did, waiting for the end to come.
Many of these pioneers have come up with ingenious solutions to enliven the daily lives of the residents of these homes, and some of the stories Gawande recounts in his book are very inspiring and hopeful – and often hilarious. I only have space to relate one such story, but it shows what is possible if one has imagination, pluck and perseverance.
In upstate New York in 1991, a young Harvard-trained physician named Bill Thomas
became the director of a nursing home. He didn’t like what he saw there, and had an idea. He wanted to attack what he termed the three plagues of nursing home life: boredom, loneliness and helplessness. So to bring some life into this nursing home, he proposed to bring dogs and cats – and a hundred parakeets -- into his facility!
The administrators thought he was nuts. Besides, this would never fly. There was no way they could get such a wacky plan approved, much less funded. But Bill Thomas was the kind of guy who would not be denied. He proved to be incredibly dynamic and persuasive. And in the end, he was able to accomplish everything he had in mind.
Once the animals came into the home, there was of course pandemonium and confusion, but ultimately most of the residents were delighted. The animals were a big hit and the residents’ spirits were uplifted. Many were brought out of their shells of isolation, as Gawande relates:
“People who we had believed weren’t able to speak started speaking," Thomas said. "People who had been completely withdrawn and nonambulatory started coming to the nurses’ station saying, ‘I’ll take the dog for a walk.’” All the parakeets were adopted and named by the residents. The lights turned back on in people’s eyes.
Researchers studied the effect of this program for two years. The findings? The number or prescriptions was half that of conventional nursing homes. The need for psychotropic drugs, like Haldol, decreased. Total drug costs fell 38% compared to other similar homes. Deaths fell 15%. In short, Thomas’s plan was an improbable but undeniable success.
Gawande’s book, though it is full of heartrending stories of people’s ultimately futile battles with their illnesses – and the reader gets to know many of these people, as Gawande makes sure to stay in touch with them – is also studded with stories like that of Bill Thomas, of people who buck the system and find ways to bring hope and compassionate care into the lives of those who would otherwise be forgotten and left to suffer.
Suffering is inevitable, of course, especially for the old and infirm and those afflicted by incurable illnesses, but ways are being found to mitigate that suffering by paying compassionate attention to the special needs and goals of people who find themselves, as many of us will one day, dealing with intractable illnesses as they approach and often yearn for death.
Gawande himself, as gifted a surgeon as he is, is very forthright about his own shortcomings as a physician when it comes to learning how to be with the dying. Doctors, after all, are not trained to deal with the dying; they often don’t know how to talk to or be with such people, and sometimes lose interest in them once they feel they can no longer help them. Doctors are taught to fix things, but you can’t fix death. If you regard death as the enemy, then the enemy always wins in the long run. It’s understandable that many doctors would prefer to ignore or slight the dying in order to attend to the living.
But Gawande in the course of doing his research for his book and talking to so many people has come to learn a lot about how to be with the dying, and he has advice for his fellow doctors, which he sums up in three questions they should be sure to put to such people:
What are your biggest fears and concerns?
What goals are most important to you?
What tradeoffs ae you willing to make, and what ones are unacceptable to you?
Gawande cites research that shows one of the most important things that doctors can do for the dying is to engage them in discussions about such issues, and not just the treatments that they could perform, which ultimately often prove useless and just extend their suffering. “Doctors everywhere,” Gawande writes, “become all too ready to offer false hopes, leading families to empty bank accounts … and take money from their children’s education for futile treatments.”
The dying don’t just want technical information, which often just confuses them, anyway. How do they know what’s best for them? No, they want doctors to listen to them, to their fears, to understand their goals, to engage with them, and not just to offer their “expert opinions.” In short, doctors need to learn to shut up at such times and listen. That can make all the difference, as Gawande notes: “People who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish.”
And eloquently concludes:
Our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversation in ways that transform the possibilities for the last chapters of everyone’s lives.
Gawande is the son of two physicians, and his father was a distinguished urologist, a man of immense energy, as healthy as “a Brahma bull,” Gawande says, but in his seventies, he finally begins to learn that he, too, will have to face his mortality. Always healthy, he becomes sick and then gravely ill. The last pages of this incredibly moving book become even more poignant when Gawande has to deal with his own father’s illness and, ultimately, with his death. I found this part of the book very tender, sad, and yet so aptly fitting, as if everything that Gawande had learned in conducting the research for his book could at the end be distilled as his final gift to his beloved father. What a beautiful tribute to a loving father from a loving son.
A Personal Postscript
Gawande does not seem to be a religious man. I gather that like most physicians he has a secular outlook on life. His concern throughout the book is of course on questions of mortality, and not with what may come afterward. But I, who have mostly been concerned in my work with what happens at the point of death and with what people realize at that liminal transcendent moment, have a different point of view. What struck me in reading this book is how desperately people cling to life, and how, even when they long to die, their families often urge their doctors “to do everything possible” to preserve their lives of their loved ones, even if that only serves to prolong their agony.
In one of my previous blogs, I recounted the case of the world-famous psychiatrist, Irvin Yalom, who resisted to the last his wife’s desperate pleas to be allowed to die because of unremitting pain from terminal cancer. She wanted death, but her husband desperately didn’t want her to leave – to leave him.
I wish people could know that when facing death, despite the pain, there is no reason to fear. I suppose I am guilty of resorting to a cliché of my own when I say that through my work, I have learned that “death is not a dead end.” Maybe I should write a book called “Being Immortal” and send a copy to Woody Allen while there’s still time. For I really do believe that we are eternal beings, and that we are all destined to return to our true home once our life on this plane ends. Maybe this, too, is something that those who attend the dying might want to keep in mind. After all, anything that could ease our own fears of dying may also serve to reassure those about to make their final passage to whatever may lie beyond this mortal life of ours.