Priorities Beyond Merely Being Safe and Living Longer

“People with serious illness have priorities besides simply prolonging their lives.”
— Atul Gawande, Being Mortal:  Medicine and What Matters in the End

November morning, Green Lake

I am adding my voice to the acclaim surrounding Dr. Atul Gawande’s Being Mortal, his newest book about the failures of medical professionals and our culture to treat the terminally sick and aged in their final months and days.  It has been about one year since my father’s involuntary move to a nursing  home following a treatable medical crisis.  And while he recovered from the emergency that brought him to the hospital and then the nursing home for rehabilitation, his other mental and physical frailties — at age 94 — prevented him from returning home to live out his last days  on the farm he loved.

So Gawande’s writing resonated deeply with me.  Our family suffered from the agonizing decisions that were made without the consensus of all nine siblings (an impossible task given the time frames we were working with and how seemingly irreconcilable our differences of opinion were). Some of the rifts are still not healed.   And while the enormous commitments from a couple of siblings kept Dad living alone in his home for many years, in the end, it felt something like a failure that he did not die at home as he wished.

We were not alone in the challenges we faced in Dad’s  last year.  We no doubt could have done better.  None of us were especially good at holding the hard conversations with Dad about the realities of his limitations.  From my perspective, it seemed that he was unwilling to make decisions and face facts.  We struggled with the idea of allowing poor choices if that is what he wanted.

Gawande says, “At least two kinds of courage are required in aging and sickness.  The first is the courage to confront the reality of mortality — the courage to seek out the truth of what is to be feared and what is to be hoped.  Such courage is difficult enough.  We have many reasons to shrink from it.  But even more daunting is the second kind of courage — the courage to act on the truth we find.  The problem is that the wise course is so frequently unclear.  For a long while, I thought this was simply because of uncertainty.  When it is hard to know what will happen, it is hard to know what to do.  But the challenge, I’ve come to see, it more fundamental than that.  One has to decide whether one’s fears or one’s hopes are what should matter most.”

I think we all can agree that merely providing safety and prolonging life are not the priorities that matter most in life.  Other concerns, such as avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden to others, and having autonomy, are perhaps more important.  And the only way to understand what matters most is to have conversations, to ask.  Gawande provides some helpful ways to frame these conversations.  He says to ask, “If time becomes short, what is most important to you?”  And here are some other questions to raise:

• What do you understand your prognosis to be?
• What are your concerns about what lies ahead?
• What kinds of trade-offs are you willing to make?
• How do you want to spend your time if your health worsens?
• Who do you want to make decisions if you can’t?

What matters changes with our knowledge of life’s fragility and finitude.  With shorter horizons, our priorities narrow and our desires change.  How can one honor a desire to live independently and autonomously when limitations and debilities become more pronounced?  Gawandwe says, “This is what it means to have autonomy  — you may not control life’s circumstances, but getting to be the author of your life means getting to control what you do with them.”  We want to continue to shape our lives in ways that are consistent with our characters and values.

I am still not clear about how to respect the wishes of an increasingly frail person if they refuse to change at all.  Dad, for example, may  have wanted to die at home, but he absolutely refused to accept outside help.  He needed 24-hour care, but would not consider visiting nurses or a paid companion.

It seems to me that at some point, one does have to let go and accept the losses that old ages brings.  It would be wonderful  if this could be navigated gracefully.  Alas, we fall short. But the end of life can be transformative and meaningful.  Gawande’s book is an important conversation about these possibilities.

 

 

Neither Young Nor Old, But Simply New

Morning clouds

Morning clouds over Green Lake, Seattle

“The clouds, the clouds, she thought.  Piled and beautiful, they were both indifferent and inviting.  They had that paradox of nature you saw also in the sea, a thing appearing eternal even as it changed every second.”
— Susan Minot, from Thirty Girls

VII
by Wendell Berry

I know I am getting old and I say so,
but I don’t think of myself as an old man.
I think of myself as a young man
with unforseen debilities.  Time is neither
young nor old, but simply new, always
counting, the only apocalypse.  And the clouds
— no mere measure or geometry, no cubism,
can account for clouds or, satisfactorily, for bodies.
There is no science for this, or art either.
Even the old body is new — who has known it
before? — and no sooner new than gone, to be
replaced by a body yet older and again new.
The clouds are rarely absent from our sky
over this humid valley, and there is a sycamore
that I watch as, growing on the riverbank,
it forecloses the horizon, like the years
of an old man.  And you, who are as old
almost as I am, I love as I loved you
young, except that, old, I am astonished
at such a possibility, and am duly grateful.

 

Wonderment and Admiration

“The longer I live the more my mind dwells upon the beauty and wonder of the world.  I hardly know which feeling leads, wonderment or admiration.”
— John Burroughs, from The Writings of John Burroughs, vol. 15, The Summit of the Years (written when Burroughs was age 70+)

“There is no other joy in life like mental and bodily activity, like keeping up a live interest in the world of thought and things.  Old age is practically held at bay so lone as one can keep the currents of his life moving.  The vital currents, like mountain streams, tend to rejuvenate themselves as they flow.”
— John Burroughs, from The Writings of John Burroughs, vol. 15, The Summit of the Years

The wonderment of Spring crocuses

Watercolor sketch of Spring crocuses

 

 

 

On Turning 60

” . . . wrinkles are the credentials of humanity.”
— George Bernard Shaw

Birthday candles

This is the year that I turn 60 and I’m thankful to have made it this far.  After experiencing cancer for the first time 27 years ago, I’ve never taken the years for granted.  I look at life as a finite gift, and I try to make something special of each day.  Looking ahead, I want to be even more economical with my remaining minutes and put my best energies into the things that matter most to me.

In the late 1990s, Cathleen Rountree wrote a series of books about the decades of women’s lives.  Each book is comprised of interviews with about twenty interesting and creative women, some famous, who share the lessons of their age.  I was curious to see what tips I might find from women who were in their 60s at the time of their interviews.  Here are some quotes from On Turning 60:  Embracing the Age of Fulfillment:

“Challenges keep life going.  If you don’t have a challenge, I think you die.”
— Elayne Jones, tympanist

“Aging is a distillation process — you begin to be more economic with your energy. . . . You realize that many things are a waste of your time, and you think, Why should I put my energy into those activities anymore?”
— Luly Santangelo, dancer

“Have younger friends . . . because when you get closer to the finish line, it’s very helpful to have people you have an emotional relationship with who are not dying or dead.”
— Mary Travers (of Peter, Paul & Mary), singer and activist

“In my late fifties I realized that I had less energy, less time to do things, and that everything took longer . . . I used to be able, as most women are, to do four or five things at once.  Do the juggling act.  Now, if I can keep one plate in the air, that’s good.”
— Ursula le Guin, writer

“My yearning now is to be free of all physical encumbrances.”
— Marion Woodman, Jungian analyst

I couldn’t resist peeking ahead to my next decade, the 70s, to see whether the wisdom and advice changed with advancing years.  Here are a few quotes from On Turning 70:  Honoring the Voices of Wisdom:

“Basically it takes me longer to do things, especially when I don’t want to do them.”
—  Marge Franz

“My experience is that there is much more consumption of culture than production of culture.  I’m talking about going to the theater, going to musical events, going to classes, learning the computer.  I don’t know if it’s typical of this stage of life, but I’m not consumed with consuming.  I get more pleasure out of the simple act of creating.”
— June Singer, analyst and writer

“I don’t think anybody makes it to a hundred in any comfort.”
— Inge Morath, photographer

” . . . I think as you get older, time is more valuable than money or success. . . .Something very important that I want to tell women is that it’s never too late, but don’t wait until it’s too late, because you won’t have the energy.  You should do a little bit at a time, but when you have a little time.  It’s important to learn how to use your small bits of time, your five minutes, your ten minutes, your fifteen minutes.  All those begin to count up . . . It’s not the long amounts of time you have that are important.  Don’t wait until your children are grown, until your husband is retired; I think that’s a big mistake.  You should learn how to use your snatches of time when they are given to you.”
— Ruth Asawa, sculptor

“I don’t have very much time to sit back and be old, because there’s still so much undone.”
— Enola Maxwell, activist

I’ve always thought that I have very wise readers based on the astute comments you make.  Do you have any pearls of wisdom for me on the occasion of me starting my  seventh decade?

Approaching Age 60

Sometimes a book arrives at just the right time in life.  I felt this way about Nothing to Be Frightened Of by Julian Barnes, written as he was turning 60.

Barnes says, “Sometimes my coevals say, in a puzzled fashion, ‘The funny thing is, I don’t feel any older.’  I certainly do.”

I’m with Barnes.  Some of my friends insist that 60 is the new 40, or that “You’re not old at 60.”  But I beg to differ.  At 60, I will be entering old age.  And I am interested in how navigating this last part of my life will differ (or stay the same) from my earlier selves.  I am the fifth of my siblings to pass into our sixth decade, but none of them remarked that it was a significant passage for them.  It seems important to me, though.

In this book, Barnes, an agnostic, writes about how writers, philosophers, friends and relatives came to terms with death, that ultimate extinction.  He writes about fear of death, fear of dying, and of seeing death as nothing to be frightened of.  I can’t say that I learned anything new to take with me on my personal journey to the end.  None of us know how death will come for us, or whether what we believe will help us die gracefully or painfully.

But I still found myself drawn to Barnes’ musings, perhaps because I think about death often, too.

“Death can’t be talked down, or parlayed into anything; it simply declines to come to the negotiating table. . . . death never lets you down, remains on call seven days a week, and is happy to work three consecutive eight-hour shifts.”  There is no escaping it.

I’ve read one other book by Barnes, Levels of Life, which touches on his recent widowhood.

In that book he says, “Every love story is a potential grief story.  If not at first, then later.  If not for one, then for the other.  Sometimes for both.”  And he goes on to say, “Pain shows that you have not forgotten; pain enhances the flavour of memory; pain is a proof of love.”

These words resonate with me, too.

Old Age and Insights

On the occasion of my aunt’s and uncle’s 60th wedding anniversary

As you know from my earlier posts about visiting my 94-year-old father on his Minnesota farm, my mind has been preoccupied with aging.  This post shares some writings that have been on my radar.

“The Joy of Old Age. (No Kidding)”
First, one of my friends and readers sent me an article by Oliver Sacks from the New York Times which he wrote on the occasion of his 80th birthday.  Sacks says, “I do not think of old age as an ever grimmer time that one must somehow endure and make the best of, but as a time of leisure and freedom, freed from the factitious urgencies of earlier days, free to explore whatever I wish, and to bind the thoughts and feelings of a lifetime together.”  Like most of us, he wishes to “die in harness,” loving and working fruitfully through the end, but he acknowledges that “the specter of dementia or stroke looms.”  I found it interesting that Sacks, this most accomplished man, spoke of some regrets, too:  “I am sorry I have wasted (and still waste) so much time; I am sorry to be as agonizingly shy at 80 as I was at 20; I am sorry that I speak no languages but my mother tongue and that I have not traveled or experienced other cultures as widely as I should have done.”  I have provided a link to the complete article, which I believe is well worth reading.

“Retiring Later May Stave Off Dementia”
Then I saw an article in the Seattle Times that cited a French study whose findings indicated that working longer/retiring later could delay the onset/progression of dementia.  My mother had Alzheimer’s and my father is now experiencing short-term memory loss, so I believe there is a rather high chance that eventually my mind will begin to go down the path of dementia.  You would think that I would find this article heartening, but I don’t!  I think this sends the message that those of us unfortunate to have dementia did not work hard enough, exercise our minds enough, eat right, or whatever, and brought this terrible disease upon ourselves.  And I just don’t believe that.  My attitude is more, there but for the grace of God, go I.

The Force of Character
Rather than thinking about old age as a medical condition, I respond better to a more sacramental approach — looking at the ageing and declining body as a source of insights and continuing soul expression and growth.  One of the best books I’ve read that talks about the “forming of character that is actually taking place in these ‘symptoms’ of aging” is James Hillman’s The Force of Character.  I first mentioned this book in this blog post.  Hillman says:

• “When the body begins to sag, it is abandoning sham and hypocrisy.  The body leads the way down, deepening your character.”
• About those mid-night excursions to the bathroom:  “Suppose, however, that the getting up from sleep awakens you not only in the night, but to the night. . . . Awakening to the night opens a dark eye into the invisible world.  It opens an acute ear to the cautions, insights, and promptings that seem to visit only at night, disturbing sleep in order to be heard.”
• “Forgetting, that marvel of the old mind, may actually be the truest form of forgiveness, and a blessing.”
• “So what is left after you have left is character, the layered image that has been shaping your potentials and your limits from the beginning.”
• “Character is refined in the laboratory of aging.”

Norwegian by Night
Finally, I will end with a great summer read, Derek B. Miller’s debut novel, Norwegian by Night.  What I love most about this thriller is its 82-year-old protagonist, Sheldon Horowitz, a recent widower who moves to Norway to be near his grand-daughter.  He’s a curmudgeon and has a philosophical outlook on life, although his nearest family sees him as a doddering old man.  They refuse to believe he was a sharp shooter in WWII and still retains his sharp mind.  His dormant skills come into play when he crosses paths with a domestic violence incident and murder in his apartment building.  I think that anyone who likes those dark Scandinavian thrillers will like this book, too.

The Laboratory of Aging

“Character is refined in the laboratory of aging.”
— James Hillman, The Force of Character

My Dad's hands at rest

I recently took a photograph of one of my colleagues at work, and I thought it wonderfully expressive.  It showed her reading from a Nook.  She laughed about how old her hands looked — my camera captured every wrinkle and age spot.  She said the next time I photographed her, she would be sure to apply hand cream first.

Another friend and colleague mentioned that she loves seeing her hands age.  Every time she looks at them, she sees them growing into her beloved grandmother’s hands.

I love photographing hands because they seem to capture something of the soul of a person.  Young or old, gestures reveal much about a person’s character.

One of the best books I’ve read about aging is James Hillman’s The Force of Character.  He sees “symptoms” of aging as particularly rich ways of forming character.  He says, “When the body begins to sag, it is abandoning sham and hypocrisy.  The body leads the way down, deepening your character.”

Hillman has much to say about old people and old things.  “Old is one of the deepest sources of pleasure humans know. . . .  We need the old pleasure-giving things, which reciprocate our love with their handiness and undemanding compatibility. . . . Even when chipped, blunted, and threadbare from overuse, old things have acquired character from familiarity, from utility, and sometimes from the beauty of luster, patina, or design.  Or simply from being old, the being of oldness.”

Hillman’s is a beautiful way to look at aging.  And I think he’s right.