For most of human history, people didn’t expect to grow old,2 and those who did often outlived their children. Because old people made up just a small fraction of the population in societies rich in children and younger adults, there was little point in considering them when building houses, making laws, designing cities, developing a workforce, or training doctors. Now most people born in developed countries can expect to be old, and there are more old people than at any time in human history. Old age also lasts longer and includes many more healthy years. Unprecedented numbers of us are or will be doing in old age most of the things younger people do, though sometimes in different ways, as well as many other things that aren’t possible earlier in life or in shorter life spans.
In societies that identified themselves by their traditions, their past, and their religion, “the elderly, closer by birth to the sacred past and by death to divine and ancestral sources3 of power,” had prestige and a clear, important social position. Today, when the past is viewed as irrelevant and death is more often seen as an ending or abyss than a chance to be with God, being old lacks both those charms. Even middle age is dreaded. Lydia Davis captured this sentiment perfectly in a one-line short story4 called “Fear of Ageing”:
At 28,
she longs to be 24 again.
Meanwhile, in my fifties, I find the idea of returning to twenty-four horrific. I don’t miss the stress or insecurity or posturing, all those things that at the time often felt—deceptively—like potential and strength and opportunity.
Old age has boundaries and landmarks that are both real and subject to interpretation. We reach no longer young decades before becoming old, and what different people and cultures count as a long time varies widely.
Like pornography, we know advanced old age when we see it. But the exact inflection point between middle age and old age is hard to pin down. It might even be impossible, both in an individual life and for our species, given the plethora of biological markers and their unpredictable behavior and interactions. Nor is culture the only other notable piece in that elusive equation. The traits that signal emergence from the liminal zone where adult gives way to old vary in the eyes of beholders. Diagnosed with cancer at age sixty, my mother resigned herself to dying, saying it was okay because she was old and had had a good life. A quarter century later, she looks back on her thoughts then, amazed at how both her perspective and old age itself have changed in the intervening decades.
PERVERSIONS
Stocky and not quite six feet tall, Clarence Williams Sr. was a recently retired seventy-two-year-old attorney who always had a book in his hand or lap. One week he’d been active and healthy, and the next he was my patient on our hospital’s cancer service. Although he didn’t have the worst kind of cancer, in 1992 all the treatments we had on offer earned the word brutal as one of their descriptors.
I looked forward to seeing Clarence on morning rounds and in the afternoons when I needed to give him test results or check how he was handling his many treatments and their side effects. He was brave and kind in many small but important ways, not the least of which was his attitude toward me, one simultaneously avuncular and respectful, even though I was a novice doctor, young, and female—three states that put off some patients. I’d like to think his generosity of character is why I remember him so well all these years later, but I suspect it’s because of what we put him through.
The oncologists started Clarence on chemotherapy within hours of his arrival. I gave him medications for nausea and pain, antibiotics to protect him from infections, and diuretics to remove the excess fluid that built up all over his body. Most days, after his labs came back, I ordered infusions of potassium and phosphorus; some of the treatment drugs, as well as some of the medications for the side effects of the treatment drugs, led to loss of essential elements. The kidneys, those small, paired organs tucked under the rib cage on the lower back, serve as the body’s garbage disposal system. When properly functioning, they remove toxins and waste from the blood and excrete them out with the urine, sending cleaned blood back into the body. If you imagine the kidneys as filters, the effect of the chemo was to enlarge the holes in the mesh such that certain molecules like potassium slid through. With low potassium levels, people have fatigue and painful muscle cramps, and their heart can slow to a life-threatening rate. With lethal potential, various minerals poured out of him, and I poured them back in, trying to keep up.
Meanwhile, ulcers formed in Clarence’s mouth and intestines, causing them to bleed. Despite the medications, he had nausea, diarrhea, and pain. His skin blistered and peeled. Antinausea drugs weren’t as good then as they are now, and he vomited so often that we used intravenous fluids to keep him hydrated. As days turned into weeks, his eyes dulled, his glasses became smudged, and his skin looked more tan-gray than brown-black. Despite his bloated body, the bed seemed to engulf him.
That was when the cancer doctors decided he needed a colonoscopy. They wanted to see how his intestinal lining was holding up and how much more chemotherapy they could give him. As reasons for ordering a test go, this was a pretty good one, since it would provide information to guide our next steps. As the team intern, my job was to make the test happen. The problem was that by this point in his treatment Clarence had trouble sitting up, and he wasn’t eating or drinking much of anything. He needed the help of an aide or two to get to the bathroom only five yards from his bed. To clean out his colon for the test, he would need to drink four liters of a liquid that looked clear but made people gag, then endure hours of running to the toilet. I looked at him, and I looked at the huge plastic container of bowel cleanser, and I thought: This won’t work.
The oncology fellow came to the same conclusion. His solution was to order a feeding tube through which the liquid could be injected directly into Clarence’s stomach. On the surface, this was a good plan. Usually a patient had to drink sixteen eight-ounce glasses of the prep liquid, one every ten minutes for nearly three hours. Clarence sometimes took a few sips of juice or bites of soft food, but even as the worst of the side effects from his first round of chemo subsided, his decimated appetite and ongoing throat discomfort made drinking large quantities of anything impossible. With the tube, we could put the bowel cleanser straight into his body without him having to drink it. Such tubes are used fairly routinely in hospitals. I had already inserted several and cared for many patients who had them. I understood their uses and benefits, and I hated them. To get to the stomach, the long, hollow cylinder of flexible plastic first had to be inserted up through Clarence’s nostril, then make a 180-degree turn and drop down the back of his throat. There, it would need to enter the right opening, the one for his esophagus, rather than the adjacent one that led to his trachea. In Clarence’s case, this was particularly important, since the lungs are a place where you definitely do not want to put four liters of fluid. Most people find both getting the tube in and the reality of having it in their nose and throat quite uncomfortable. Still, sometimes it goes in quickly and easily enough.
Sometimes. Not surprisingly, many patients also hate these tubes. During insertion, the tube doesn’t know it’s supposed to make a downward turn and often tries to keep going up, digging into the soft tissues in the back of the patient’s nose and throat. Even when it goes in smoothly, people often gag or hover on the brink of gagging. People who are confused just pull it out … unless their arms are tied to the bedrails, in which case their existence is reduced to something that looks suspiciously like torture. There is, after all, a plastic rod where it doesn’t belong, so the body says: No. That was Clarence’s body’s reaction and also mine when I saw what the tube was doing to him.
Worse still, the tube insertion was just the beginning. Clarence’s nostril itched, swelled, bled, and dripped. His eyes watered. He had a choking sensation and searing pain as the tube pushed against the chemo-ravaged back of his throat. He was torn between wanting to swallow the irritant and not wanting to swallow ever again because it hurt so
much. When a nurse began pushing the fluid through the tube to his stomach, his belly bloated and churned. His nausea worsened. He retched. She slowed down but kept going. An hour later, the fecal urgency began. If you’re fairly heathy and recently turned fifty, earning yourself a screening colonoscopy, such urgency is manageable. But when you’re seventy-four and have been in the hospital for weeks, when your cells have been under siege from chemotherapy, when your muscles have shrunk from disuse, and when, because of all this and more, your cancer and its treatment are getting the best of you, well, then, even getting to a commode placed beside your bed can seem about as possible as running a marathon.
When the pressure built inside Clarence’s belly, he pressed his call button. When no one came, he called out with his weakened voice. And then? Rarely does anyone come quickly in a hospital. Everyone has too much to do, and nurses and aides can’t abandon whomever they are caring for at that moment unless someone else’s life is in jeopardy.
Clarence knew what was about to happen, and he hated it. He considered getting up, but knew he would fall, and also that if he hurt himself badly enough by falling, the chemo and all his suffering would have been for nothing. So instead he lay there as a warmth seeped around his lower torso. His chemo-raw skin stung. He closed his eyes, though less from the discomfort as from his shame. Only a small child shits himself, he kept thinking, and if that was where he was at, then he had come full circle. At least, that was how it looked to me when I checked on him. His eyes and expression said he knew his life was almost over, and this was how it was going to end—alone, miserable, and undignified.
In medicine, a colonoscopy is a “minor” procedure. Although major procedures are major for everyone, the same is not true of those labeled minor. That designation, based on the procedure’s difficulty for both doctor and patient, does not take into consideration the particulars of the patient receiving it. It also encourages the use of such procedures in people and circumstances where they do more harm than good,5 most often in the very sick or very old. When doctors do discuss the risks and benefits with patients, too often it’s to meet a legal requirement rather than to inform, inquire, and collaboratively conclude. The focus, other than getting it over and done with, tends to be on side effects and adverse incidents. We don’t have language or record-keeping mechanisms for the experiential facts of procedures, the in-the-moment trauma and its subsequent distress.
Clarence Williams entered the hospital as a “young-old” person who clearly enjoyed his life. In his few weeks on our cancer service, he became a prototypical old man, sickly and frail, his coming death writ on both body and spirit. Witnessing this horrified me, but like so many of us I said nothing and continued doing my job. Sometimes he and I would simply look at each other for a few moments after completing our usual tasks and conversations. In those moments, we discussed all that was never said aloud in a wordless universal language unrecognized by my profession.
That month, I watched the oncologists save many lives. All ages and cancer types. I also watched them ruin many lives. All ages and cancer types. That is medicine, and that is life.
Clarence’s existential suffering never came up on rounds. Instead, we talked about his chemo cycles and potassium level, his symptoms and next procedure. Eventually, we began talking about when he might leave the hospital, headed most likely to a nursing home, given his weakness and poor prognosis. We hoped that he would gain weeks or months of life from the chemo—an unlikely scenario, seeing how sick it had made him, though we couldn’t know for sure, since the regimen hadn’t been studied in patients his age. We didn’t discuss the obvious: that he was unlikely to spend any gained time feeling well and doing the things he enjoyed. Maybe he would have wanted the treatment anyway, as some people do and in case it helped. This was years before we knew that some people, particularly older adults, live both longer and better without treatment for certain clearly fatal cancers. Or maybe Clarence wanted the chemo and then, once it was clear how bad it would be for him, changed his mind but couldn’t find a way to get off the high-speed treatment train. Perhaps it didn’t occur to him to ask about other options.
It didn’t occur to me to offer any. Partly this was because it wasn’t my place; the oncologist was his primary doctor and I was his lowest assistant. But the real reason was more fundamental. I didn’t know what the alternatives were or how to arrange them. On the cancer service, we learned only about chemo and radiotherapy. Although age is the greatest risk factor for cancer, and cancer is the second most common cause of death, geriatrics and palliative care were not part of oncology training programs. With few exceptions, they still aren’t. A doctor is unlikely to make assessments and recommendations she doesn’t know how or when to make.
It is our right as Americans to demand care that makes no sense. To insist that our bodies be crushed, disfigured, and disrespected, that what once was sacrosanct be intentionally and systematically desecrated. That American right asks doctors to do the impossible, the ugly, the appalling. Some enjoy the sport of their procedures and expertise; for others, motivated by a desire to heal and help, doing such things erodes the softness of them, leaving wounds they cover with callus and corruption. It is the war zones of our body politic and the vast wastelands of our health care system that allow us to commit such travesties and label them care.
REJUVENATION
The woman behind me in exercise class was pretty, maybe even beautiful, one of those women whose face looks better at eighty than mine did at twenty. Yes, I could tell she was well into old age—dyed hair, plastic surgery, and makeup notwithstanding. But she looked good, and I became even more impressed as she lifted weights and did planks and push-ups, squats and crunches. I noticed she couldn’t fully straighten her arms or legs and thought: She’s so fit and still she has contractures. The youngest she could be, I decided, was late seventies; more likely, she was in her early eighties. I wondered if she’d taken up exercise late, or whether tendons hardened and shortened in some people despite regular exercise. But I also had a moment of shock about forty minutes into the workout when we lay down on our mats. As her hair flowed away from her forehead, pulled by gravity toward the floor beneath, the contrast between the lustrous blonde-brown of it and her translucent skin seemed wrong. Worse than wrong, it was disturbing. Without the hair’s protective framing, I saw where her skin had been pulled and tucked and how it fought with itself, surgical residua pulling one way and gravity another. Suddenly, she didn’t look pretty. She looked like a mannequin in a horror film. At some point, when you take one thing and try to make it another, you run the risk of the grotesque. Probably they didn’t tell her about this risk; maybe she didn’t care. Almost everyone values the present more than the future.
An Internet search of the term anti-aging yields over forty-six million hits. The first of many items that come up are lists of tips, secrets and routines (some “recommended by doctors”), beauty products, and clinics that promise to help minimize the impact of aging on skin, body, and mind. The most frequently used words include prevent, reversing, and corrective, followed by age spots, hormones, and wrinkles, though younger-looking, refreshed, lively, and robust are also popular. Much of this language is borrowed from science—smart marketing that lends legitimacy and an aura of truth, rigor, and objectivity to what is mostly cosmetics. It also reinforces, overtly and insidiously, the idea that aging—even though we are all doing it all our lives—is bad, that old is ugly, and that evolution over a lifetime is evidence of failure. They offer the hope6 of an old age absent all that leaves us feeling unattractive and all that we fear.
In the twenty-first century, many scientists have concluded that tackling human health one disease at a time makes little sense. Incredibly, even if we cured all of today’s big killers—cancer, heart disease, dementia, and diabetes, to name just a few—we would only gain a few extra years of life. Our parts would still wear down and out. (As Oedipus said, “Only for the gods / Is there never old age or de
ath! / All other things almighty time confounds.”) According to this relatively new “geroscience hypothesis,”7 since aging is so closely linked to illness, debility, and death, the best way to address those problems is by interrupting the aging process8 itself. That approach could allow simultaneous prevention (or, more likely, delay) and treatment of multiple aging-related diseases and functional impairments, from osteoporosis to diabetes, heart dysfunction, and frailty. In the pipeline already are treatments like resilience therapies for high-risk older patients, making them less frail and vulnerable to disease, and medications that would remove inflammatory protein-producing cells that harm nearby tissues. The goal of most such treatments is to increase our healthy years, or “health span,” rather than our life span. Of course, some people would like to do both.
The search for eternal youth dates back to at least to 3000 B.C. in Babylon, when Gilgamesh stated that a long life could be achieved by pleasing the gods with prayer, heroism, and sacrifice. Ancient Chinese emperors sought an elixir of youth, and ancient Hindu writings, the Vedas, hinted at alchemy that offered not just the promise of ongoing vitality but an actual return to youthfulness. In Europe, the idea gained and waned in popularity over centuries. In the fifth century B.C. Herodotus wrote of a people who all lived to 120 years old9 and claimed their secret was bathing in a particular fountain. In medieval times, a Golden Age or Place of eternal youth was sometimes presented as having once existed and other times as still existing but hidden, so it or the secret to it needed to be discovered.
Others focused less on youth and more on longevity. In thirteenth-century England, Roger Bacon drew on ancient texts and Christian beliefs in the natural immortality of humans before the Fall to posit that proper behavior could extend the human life span to 150 years. If future generations continued the same beneficial practices, he also suggested, human lives might reach three, four, or five hundred years. The same themes recurred over time: seeking youth, living longer, and restoring (sexual) “vitality.” Approaches often echoed earlier periods and beliefs about aging. A long-standing view, derived from Galen’s waning vital force theory, held that an element or humor—breath, blood, semen—from the young could be used to improve the health, energy, or beauty of the old. Invoking that reasoning, some recommended living or sleeping with the young to draw warmth from their proximal bodies. (The latter option may have been popular for reasons other than health …)
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