“It’s new,” my colleagues told me. And: “It’s a huge step forward. Give it five years.” I knew they were right, and also that none of the new units for cancer patients or kids or pregnant women were opened so far below established standards. We weren’t the only hospital approaching the care of old people this way—and our outcomes are far better than most—but I suspected mine was one of the few specialties that expressed such profuse gratitude for inadequate facilities, staffing, adherence to evidence, and control over the care of their patients.
I loved my first day. I loved our patients and loved working with the dedicated, elder-friendly occupational and physical therapists, even if they couldn’t attend our team meetings. Everything was new and exciting, the start of something needed and wonderful.
The second day brought an awareness that no one I was dealing with seemed very happy about the new ACE consult service except the physical and occupational therapists. Only two of the many floor nurses I interacted with seemed interested and engaged. The case managers had to be tracked down and didn’t see why they had to speak to someone not on the primary team. Several of the doctors on whose patients we consulted responded by protecting their turf; the majority didn’t respond at all. The clear message from almost everyone I interacted with was that although people had heard of the new service, it had been started over their objections and they resented its presence and intrusion. They didn’t recognize the problems ACE needed to address; instead, it was yet another bureaucratic sinkhole sucking their precious time.
On the afternoon of that second day, a nurse asked if I could do anything for a woman in evident discomfort whose care plan made no sense. She walked me down the hall and pointed at a tiny semiconscious woman moaning and writhing in her bed, her brown skin pale yellow and draped like loose tissue paper over what remained of her.
From the doorway, it seemed obvious to me, as it had been to the nurse, that Georgia was dying. I went to the computer and looked her up. She’d been in the hospital for months, mostly in intensive care. At one time or another every organ had failed, but because Georgia had said she wanted “everything done,” that was the approach being taken. Her family, who hadn’t been to visit for some time, wanted to respect her wishes. So now, instead of palliative care, she was slated to get a big intravenous line and a course of dialysis. I called the hospitalist, who said it was worth a try and they didn’t want to “give up” just yet. I offered another perspective but to no avail. Each time I passed her room, Georgia was moaning and writhing. Late that day, they inserted a catheter and cleaned her blood. Two days later, her family arrived and said she’d never want to live “like that,” meaning the way our hospital “care” had made her. That afternoon, Georgia moved to the hospice suite, where she quickly and comfortably died.
On the third day, I arrived at the windowless residents’ room and sat down at one of its computer terminals. As had been the case the previous morning, across the hall a young patient was screaming and cursing with pain. Cancer was eating away at his organs. As I had done the day before, I went out to see what I could do and was told it was under control. Back in the residents’ room, I changed to my computer glasses and still had trouble reading the electronic record. Feeling more settled in my new role, I decided to address the issue. I called IT and was told there was nothing they could do. I called Facilities and learned that my unit could request a different terminal that might arrive in six months. I called my disability contact, who told me his work-around; but when I tried it, it didn’t work on those terminals. The young man across the hall was still screaming and cursing. Through the residents’ room’s little window, I could see staff in his room and also that his gown was partway off, revealing some of his death-blackened parts. They seemed able to make him comfortable later in the day and I hoped they were working on a strategy for mornings too. I went back to my terminal, squinted, and got to work.
Later that morning I had a new consultation. Rafael was in his late eighties and a huge baseball fan. After a nice conversation that included mention of his daily walks in the park across the street from his house, I moved on to the physical exam only to find Rafael couldn’t lift his right leg at all. I phoned the primary team, told the hospitalist what I’d found, and offered to help with the many tasks that needed doing. “No!” she snapped. “I’ll take care of it.” And then she hung up. Ten minutes later, in the hallway outside Rafael’s room, I introduced myself. She shook my hand and walked away.
By my fourth day on the ACE unit, I was heartsick, a term that has gone out of favor but seems apt here. I read the overnight reports on the patients I’d been following and chatted with the rehab therapists as they did the same. Residents came and went, mostly ignoring us. The young man across the hall moaned. I looked up a few ACE research papers trying to find criteria for patient selection, since our unit didn’t yet have any. Then I picked several new patients to see that morning, reviewed their charts, and walked down the hallway to a small, dark room with a locked door and telephone. Since the unit’s director was out of the country, I called the next person up the chain and told her I was sorry, really and truly so very sorry, but I couldn’t work on the ACE unit; I just couldn’t.
She was kind and helpful, and the nicer she was, the more I unraveled. Suddenly, I didn’t know why I’d become a doctor. I felt the full trauma of every horrible thing I’d ever seen or done as a doctor and all the ways people suffer—even, or perhaps especially, in a place where everyone was working hard to help. As a person who had most recently been in such places as a patient and patient’s daughter, the sounds, sights, odors, and emotions seemed like those you’d expect in a place designed for low-level torture, not healing. Either my burnout wasn’t quite over, or in middle age I no longer could suppress my normal human responses to such concentrated misery.
In addition to that personal reaction to the hospital, I was also struggling ethically and philosophically. It was great that our medical center was finally taking an interest in old patients. And I was pleased that the higher-ups had started using jargon like “age-friendly health system,”5 which the World Health Organization defines as one that meets the needs of older people6:
As people age, their health needs tend to become more complex with a general trend towards declining capacity and the increased likelihood of having one or more chronic diseases. Health services are often designed to cure acute conditions or symptoms and tend to manage health issues in disconnected and fragmented ways that lack coordination across care providers, settings and time.
Health systems need to be transformed so that they can ensure affordable access to evidence-based medical interventions that respond to the needs of older people and can help prevent care dependency later in life.
Although I appreciated that our institution was finally at least paying some attention to old patients, I feared the ACE unit’s unwelcome status and narrow focus would reinforce people’s prejudices about old people and geriatrics. Our consults were largely limited to geriatric syndromes and the collation of data obtained by others into a plan of no apparent interest to primary teams.
Those last sentiments didn’t go over very well with my colleagues. They kept telling me how envious people were at other institutions where geriatrics still got no attention at all. I agreed wholeheartedly with their very good points about the need for patience with culture change. But I couldn’t help but think of a different metaphor. To me they sounded like a battered woman saying, Things are so much better now: he still hits me but hasn’t knocked me unconscious even once this year.
I finished out the week, and the next week a colleague took over. At an academic medical center, there are always other roles to play and jobs to do. My first brief stint on our ACE unit wasn’t my finest moment as a doctor or human being, but it would turn out to be the sort of “midlife crisis” that moved me closer to the joy of elderhood—that period of life when a person is clear about who she is and what she values. I’m an outpatien
t doctor with a low tolerance for patient distress who works best in a supportive, creative, collaborative environment. I wasn’t sure at first where I’d find that. But I did find it, and I didn’t have to go far. I just had to look at the world, at my medical center, and at medicine, from a slightly different angle.
WORTH
My octogenarian mother is cutting cheese. Always short and even shorter since a fall and vertebral compression fracture, she is having trouble getting enough height and leverage to cut through the huge, hard triangle of Gouda. I worry the knife will slip and she will cut herself. I consider that I could dispense with the rind more quickly, easily, and cleanly. Then I remind myself that I am more often absent from than present in her kitchen, and she is neither starving nor covered in cuts and bandages. I take a deep breath. We are not in a rush, and since the cheese will simply be part of a midafternoon family snack, it doesn’t matter whether the slices are elegant or even of similar sizes. In this scenario, I’m the one with a problem. Sometimes speed matters, sometimes things need to be done just so. This is not one of those times.
Modern life is so focused on time and speed and doing multiple things simultaneously that old people often are called “out of touch” or “behind the times.” But emerging data on social-media-related anxiety combined with the amount of money spent on spas and relaxation apps suggest we could just as easily say the rest of us are rushing and stressing ourselves to misery and premature aging. Relative to young people, old people may do x and y more slowly, but it might behoove us as individuals and society to consider which situations truly require speed and which require only that a task is done well. What problems need solutions and which do not?
Although older adults as a group hold a disproportionate amount of wealth, the average older adult of today, often no longer generating work income, is not wealthy. While those in upper income brackets tend to oversave,7 people with less to begin with get poorer by the year.8 Both are working in increasing numbers, albeit for very different reasons, to the point where the so-called encore career may become the new normal. Recent studies show an increased risk of death in the two years after retirement9 for men in their sixties and that over 40 percent of older people, fitter than those of previous generations in their age group, are “unretiring.”10 In our society, increasingly dominated by the tech industry, where thirty is old and forty is ancient, people in their seventies are the fastest-growing segment of the working population.11 Some return to the same work; others do something new. Many work fewer hours than they did in middle age. This is often by choice—one of the benefits of being old—but sometimes it’s enforced by a culture that simultaneously laments the “burden” of old people’s unemployment12 and prevents them from working. Most unretirees looked forward to retirement or accepted the social mandate for it only to find that their lives lacked purpose, social engagement, or needed income.
“Nothing hastens old age more than idleness,” wrote the sixteenth-century French physician André du Laurens. A useful vision of aging, he believed, had to go beyond biological destiny to include the need for purpose and activities. A century later, even advocates for the care of old people often made their case not by arguing for a different view of old age dispositions and function but despite them. In 1627 the physician François Ranchin argued that medicine needed to pay more attention to the health and care of old people. He admitted it was a hard sell, since “not only physicians, but everybody else attending old people” were “accustomed to their constant complaints and [knew of] their ill-tempered and difficult manners.” Caring for them, he insisted, was therefore “noble and important … serious and difficult … useful and even indispensable13 …”
As director of the New York City Farm Colony in the 1930s, Ignatz Nascher “tried to promote incentive to work, stimulated pride in appearance, tried to improve attitudes on life, created reading and games rooms, made workers’ clubs, stimulated competition with private clubs, etc.,” among aged public dependents. Around the same time in San Francisco, Lillien J. Martin, the child psychologist, realized that disturbed behavior in children was often the result of the presence of an older person at home who was upset and unhappy, not because of physical discomforts or ailments, but by a loss of purpose and self-worth. The work of psychotherapy in old age, Martin advised, required “the double task of breaking down a prevalent social misconception [that old age means only decrepitude and misery] and rebuilding a personality that has accepted that misconception14 and all the misery that goes with it.” Her work implied that the “ill-temper” of old people so upsetting to families and physicians over centuries was manufactured by social expectations that stripped them of opportunities to meet essential psychic needs that don’t change across human lives.
Here are words often used for old people today: Irrelevant. Useless. Burdensome. Ugly. Inferior. The same has been said of babies, disabled people, various races and nationalities—for most people at some point or other and for some nearly constantly. Let’s examine these words and concepts one at a time.
Whether something is relevant or irrelevant is a matter of who and where you are and what you value. It’s different for different people: the same person can be irrelevant in one arena but relevant to another. This concept of relevance is most often invoked by people who believe their own work, world, and worldview to be more important than others’ and inherently implies conceit on the speaker’s part. In San Francisco, young techies often lob the word around, setting up an us-versus-them, hip-versus-“old” dichotomy into which all humans are segregated. Perhaps the average ninety-year-old isn’t designing the latest technology, but neither is the average twenty- or forty- or sixty-year-old. Most people aren’t in tech, even if they regularly use it, which means by the prevailing techie logic of relevance, most of us are irrelevant. (So, for whom are these relevant techies designing?) And then there’s this: Silicon Valley is scrambling to “capitalize on the silver economy,” as the Economist magazine has phrased this booming business opportunity. From job search sites and ride-hailing apps to assistive robots and smart hearing aids, tech for older adults will not work unless designed with and refined through testing with older adults, which makes old people active participants in the tech economy.
The label useless similarly depends on what counts, and one’s values. If usefulness is defined as contributing to society by working, huge swaths of the population are useless: children, homemakers, many disabled people, most homeless people, and the unemployed. Families often provide for the needs of people in at least the first three categories. We accept that; many people even applaud it. So that version of “useless” can’t be right. Ideally, families take care of whichever members need care at a given time, and who that is varies throughout most lives. Some people argue that children are different because we are investing in their future. But all children grow into adults, and many adults don’t meet the expectations implied by this rhetoric. On the flip side, many older adults have already made contributions. One could argue they are a better bet than children, offering opportunities both to repay society’s debt for their contributions and to create an incentive system for others to “earn” a good old age in earlier years. But there again, we’d have to judge what counted as a contribution; those who didn’t make the cut would be in dire straits.
Burdensome. Anyone who has ever been a good friend, a spouse or partner, a parent, an engaged adult child, or an employee knows burden is one component of every relationship of any significance. Sometimes we take on the burden because we have to, because we need a job or want to be a good person. Other times the burden is just one part of an overall satisfying relationship. Eliminate everything that qualifies as burden, and there’s little of life left.
As for “ugly,” one person’s ugly is another’s cute, if not handsome or pretty. Other times, ugly is an accurate descriptor. Some categories of people are more famous for their looks than others—Ethiopians, Scandinavians, Southeast Asians—but in all peopl
es and all age groups, some people are better looking than others. Many babies are ugly. Ditto many teenagers. In old age, people are far less likely to have the attributes associated with beauty and so are sometimes seen as ugly.
Inferior suggests a hierarchy, and in any hierarchy, there is only one superior position. If we are looking at the entirety of the human race, or even just the citizens of one country, it will be hard to identify, much less agree on, who holds that one superior position. By definition, the rest of us (most people) are all inferior, regardless of what attribute or scale we choose. Could we say that older adults are, as a group, inferior at generating income and maintaining the economy than middle-aged adults? Perhaps, if you count earned income, not wealth, and if you ignore the years they already put in generating income and maintaining the economy. Can it really be that entire generations earn no credit whatsoever for services rendered?
Judging lives based on utility and contributions creates a slippery slope: What then of kids, the lazy and less productive, the less talented, the less fortunate, the sick, the less wily and ambitious? What of the “weaker sex” and the “inferior races”? Put together the full panoply of human prejudices and what’s left is a small percentage of people, with the rest of us in the worthless category, and that small group headed inexorably toward worthlessness. If a certain brand of productivity is our only standard of worth—or of worthiness for care and compassion—we’re all in trouble.
BELOVED
“I am more interested in the positive pathologies,”15 declares Oliver Sacks in Bill Hayes’s Insomniac City, a book that is a triple love story—to Hayes’s first partner, Steve Byrne, who died suddenly in his sleep at age forty-three in their sixteenth year as a couple, to New York City, where Hayes moved after that unimaginable loss, and to his next partner, Sacks, who died at eighty-two when Hayes was in his early fifties. The centrality of these deaths to the story might give the impression that the book is sad. In fact, it’s luminous, enchanting, and often funny. Similarly, the ages at which Steve and “O,” as Hayes refers to Sacks in the book, die might make it seem as if the former were the greater tragedy. It was for Steve, given all the decades he didn’t get to live, and perhaps for Hayes himself in the more immediate aftermath of Steve’s sudden death at what he likely imagined to be just the midpoint of his life. Yet, with the tincture of time and a generous curiosity reminiscent of O himself, Hayes portrays his two lost loves as merely different, neither greater nor less than each other.
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