Elderhood

by Louise Aronson

  In Ways of Seeing, John Berger shows that what we usually accept as objective reality21 changes depending on how it’s presented to us. He notes that how we see things is affected by what we know and what we believe, as well as by the information we are given and the context of our viewing. A landscape of wheat fields with birds flying overhead appears charmingly bucolic until you learn it was Vincent van Gogh’s last painting before he killed himself. People who are told the same image is either a work of art or a record of everyday events evaluate it using mostly divergent criteria. With different background music, a painting of a group of men talking over dinner takes on very different tones; it can be playful or sinister, affectionate or angry. We come to disparate conclusions depending on what we are told: Is that shrunken, bent old person an escapee from the local nursing home or the author of the Supreme Court’s latest erudite and transformative ruling?

  What we see depends on more than what we’re looking at. Even when we are trying to be objective, what we consider “fact” or “reality” depends on what precedes, follows, surrounds, and accompanies it, who we are and what we already know and believe, where we are when we see it, and whether we are shown the whole or just one small part of the picture. The same object, idea, or person, approached in different ways, can seem to mean very different things.

  A friend asked me what she could do about her mother’s “old lady smell.” Even as I write those words, as I surround them with quotation marks, I want to protest, yet I knew exactly what my friend meant. She didn’t just say that her particular mother had a surprising, noxious odor but that her mother had acquired something sufficiently common that it had its own phrase, one with the inescapable ring of truth, if also with the clang of stereotype and the grate of insult. A clean older person smells like any other clean person. But people’s olfactory sense declines with age, and washing becomes more physically challenging or exhausting. Because of waning sex hormones, old people generate less odor than younger people. Frequent showers and clothes laundering begin to seem only occasionally worth the effort; the differences between recently cleaned and cleaned a few days prior are often undetectable to aged noses and eyes. Unwashed hair and skin and clothing take on a sour mustiness they don’t notice.

  The smell of an unwashed old person is different from the odors of an unwashed teenager or adult. At different life stages and by virtue of hormones and eating habits, our bodies contain different distributions of cells and bacteria, oils and chemicals. Tell an old person that they smell, and most are mortified—I would be. They didn’t realize, and why should they? If we mention old age odor at all, we mostly ascribe it to old age itself, not to the behaviors and logic behind those behaviors. Contrast that with our approach to adult odor for which we have gym showers and deodorant and foot, jock, and feminine sprays. We offer no equivalent triggers or aides for “old person smell.” Those same things would help but often aren’t primarily what is needed. Adults need to mask the stronger odors they produce in the course of a regular day; very old people usually just need a world that makes it easier for them to wash more regularly.

  Emphasizing the declines of aging and pathologizing life’s normal progression while ignoring the essential roles played by our perceptions and physical and social environments creates disabilities where there might be only differences.

  As a doctor, I find the hardest part of helping people (of any age) with advanced illness comes from knowing I can’t fix the widespread cancer or end-stage lung disease, her failing brain or his permanently paralyzed left side. These feelings are, I suspect, one of the main reasons so many people (and doctors) avoid ill, debilitated, or bereft old people: the sense of one’s own apparent inutility as a helper. But in indulging those discomforts, we make the ideal the enemy of the right, the kind, and the needed.

  Imagine aging in a world where we spent less energy lamenting what is gone and more supporting what is present. Imagine doctors (and people generally) able to tolerate and talk about uncertainty. Imagine a society that accepted the facts of every life throughout history: we are born, we die, and in between, the lucky live by developing, changing, and aging. With this existential skill set—accessible to anyone, for free—we can be much more practically useful than we are now to people of all ages. Equally important, we will accept that sometimes we won’t be at all practically useful, and that the missing pragmatics need not equate with inutility unless we consider kindness and human connection useless.

  Some days when I was doing housecalls, I suspected the most important thing I did—or at least that which was most appreciated by some of my patients—was to act as a friendly visitor. I might be their only visitor for days or weeks, or one of few, or the only one who really talked to or touched them. I liked my patients, and they knew it. We laughed. If it seemed appropriate, I rested my hand on their arm. I almost always lay my left hand on a patient’s shoulder when listening to their hearts or lungs. Sometimes my housecall patients clutched and squeezed my hand. Sometimes they hugged or kissed me. Sometimes they commented that they couldn’t recall the last time they touched another human being.

  My patients didn’t do those things because they were old, although the desexualizing and relative powerlessness of old age make hugs and kisses acceptable in situations where they otherwise might be considered inappropriate, or even sexual harassment. They were starved for basic human contact, a need that transcends culture and age. That need is not a biological imperative of aging; it’s the result of choices we make as individuals and as a society. We let people vanish, treating them as less than human. We tell ourselves stories of how grotesque older skin is, but hush the cultural messages inside your head, and you’ll find that old skin is soft and warm and a pleasure to touch.

  Consider all the public figures and neighbors and relatives you have who are visibly and undeniably old. Maybe they move slowly or maybe they don’t, but you know they are in their eighth or ninth decade or beyond. Some are frail and dependent, and most are not. Yet until recently, when we heard the word old, we thought disdainfully of the people in the first group and pretended all those others were not old.

  That’s starting to change. The writer-activist Ashton Applewhite, author of This Chair Rocks, tells the story of an East Coast performance festival organizer who chose aging as the festival’s theme in 2012. The organizer’s friends warned she would lose all her subscribers. Instead, festival subscriptions tripled.

  A few years later, the same thing happened to me and two colleagues when we were invited to speak about “optimizing aging” at a salon-style forum in the Napa Valley. The organizers kept warning us that attendance varied a lot, depending on the topic. It became obvious they thought our topic, the very topic that interested them and inspired them to invite us, might be off-putting to others. The evening of the event, it was standing room only, and we had to cut off the questions so people’s dinner wouldn’t get cold.

  In 1995 Isabella Rossellini had been “the face” of Lancôme22 cosmetics for fifteen years when they dismissed her. She was forty-two years old. The company said women bought cosmetics to fulfill their dreams of youthful beauty, and she was too old.

  It’s probably worth stating the obvious: in her forties, Rossellini was more beautiful than most of us are at any age. Ditto in her sixties, but I’m getting ahead of the story …

  Fast-forward twenty-three years. Rossellini, by then sixty-five, was told that Lancôme wanted to hire her again. She thought it only right to let them know that she hadn’t gotten any younger in the interim, and if she was too old in her early forties to represent women’s dreams, she didn’t see how the new arrangement could possibly work. She insisted on an in-person meeting. She wanted them to see her face in its seventh decade.

  At the meeting, the company’s newish female CEO explained that many women felt excluded and rejected by the endless parade of only young models. They wanted to define beauty not as youth alone but as something different and more inclusive. Perhaps th
ey wanted to hew more faithfully to the dictionary definition: “a quality of a person or thing that gives pleasure to the senses or pleasurably exalts the mind or spirit.”23

  Describing the experience with a grin, Rossellini certainly fit the bill. “So probably women’s dreams changed, did they?”

  13. AGED

  TIME

  One fall, we asked our vet how we would know when it was time to put down Byron, our elderly dog. He was fourteen, half-blind, partly deaf, with dementia, arthritis, and an enlarged prostate. He occasionally walked into walls or stood staring vacantly with his tail down. He had begun wandering and whining for reasons we couldn’t always decipher.

  Byron had many age-related afflictions, but it was also true that he often toddled along happily on his daily walks. He sniffed bushes and stained storefronts with the measured attentiveness of a research scientist, flirted with passersby, and on occasion raised his ears and tail, marked a spot, then kicked his hind legs while growling, barking, and asserting his dominance over some generally long-gone canine competition. Since Byron was an elderly eight-pound Yorkshire terrier, this invariably provoked fond smiles in passing strangers.

  Attentive to Byron’s needs, we softened his food with water and sprinkled it with meat; we cuddled him when he whimpered and took him outside to relieve himself four, five, even eight times a night. We couldn’t take a vacation because we couldn’t imagine asking anyone, friend or dogsitter, to do what we were doing. Nor could we fully trust anyone to provide the care we thought Byron required.

  When asked whether it was time to put Byron “to sleep,” our vet said he used the 50 percent rule: Were at least half of Byron’s days good ones? Or was it one good day for every bad, or two bad days for every good? When you get to the latter, he explained, it’s time.

  This conversation gave me pause for two reasons. First, what did Byron want? Was 50 percent good enough for him? There was no way to know. Which brought me to my second reason for pause: my patients were the oldest, frailest, and sickest of old people, yet many were quite satisfied with their lives.

  This isn’t true for everyone at the far chronologic reaches of life. Some people are eager to say they’ve had enough after they find themselves bedbound or dependent, unable to do any of the things they once valued so dearly. Still others cannot express their wishes or needs but lie in bed or sit propped in chairs, frowning and grimacing despite attentive care and trials of antidepressants and pain medications.

  “Why don’t God want me?” Mabel asked just before her ninetieth birthday and four years after a big stroke left her bedbound and fed through a tube.

  “Can’t you do something?” begged an eighty-nine-year-old with advanced Parkinson’s disease and incontinence who would have killed himself if only he still could.

  If we had a 50 percent rule for humans, they would have welcomed the opportunity to end their lives. As it was, they had lived full lives, knew those lives were over and not coming back, but lingered. Yet others, even those with similar or equal disabilities, feel just as strongly that they want to preserve their lives at any cost.

  Of course, we can’t have a 50 percent rule for humans. Because who decides? These are vulnerable people, and while the world is full of dedicated, self-sacrificing caregivers, it also contains far too many people who stand to gain from death (through inheritance) or from ongoing life (in the form of Social Security checks or cheap housing).

  At the same time, even if not everyone feels the despair those two patients of mine did, what if millions or tens of millions of others do? Are we going to ignore that fact, especially when we are responsible for that reality people find not worth living? Is there a difference, practically and morally, between grave illness in advanced old age and at early stages of life?

  Over Byron’s last year, he’d had a number of health problems, and we had intended to take a palliative approach: doing only treatments that lessened his suffering and avoiding tests and stressful vet visits. But just after we made that decision, when he was slow and slept more but seemed otherwise fairly content, his paw hurt, so we took him in. Other medical issues followed. A few months later, Byron was short of breath. We thought that was the end, but the vets disagreed. They said he needed nothing more than an X-ray to determine it was pneumonia, then oxygen and antibiotics. Without explicitly saying it, they implied that not treating such a treatable condition was dog murder. Each time he had to go to the vet, Byron shook, panted, climbed up our bodies, and tugged on his leash, his tiny body straining for the door.

  Suddenly, I fully understood something I had observed at work: how it was possible to love a frail loved one, prioritize his comfort and well-being, yet repeatedly find oneself doing things that felt awful to everyone.

  The situation was made worse by both a lack of consistent consensus within our family about what was the right thing to do for Byron and the well-meaning veterinary doctors. It’s hard and morally unsettling to discuss a comfort-only approach with health professionals advocating for an “easy” treatment for a fixable problem. The same thing happens with humans for logical if not ideal reasons: a focus on diseases as individual entities, rather than the person’s larger and more complex situation.

  Eventually we realized we’d passed some no-going-back landmark in Byron’s apparent well-being and made an appointment with a hospice vet. When I returned home from work on the designated night, the humans of our family were cradling Byron and looking sad. He came to me, wiggling his tail and dancing around as best he could. He hadn’t eaten all day. I thawed chicken, and he gobbled it down. Someone said, “You can’t kill him.”

  Then he followed me to the bathroom and vomited the chicken onto the floor at my feet. He stood, tail down, facing the wall.

  Byron died in my arms that night.

  Both before and since Byron’s death, I worried that we waited too long. We counted the time he spent sleeping as contentment, tipping the scale above the 50 percent mark, when I know in elderly humans sleep is more often a sign of chronic exhaustion, depression, and avoidance of pain. In dealing with the guilt brought on by our mixed feelings—we love him; he’s ruining our lives—we may have overcompensated to his detriment.

  With dying humans, similar situations arise every day: hospital stays that fix the acute problem and worsen the chronic ones; emergency department visits that yield diagnoses but require weeks of recovery from the waiting and testing; surgeries that are themselves minor but provoke major confusion, complications, and hated nursing home stays. But there are, too, the relatively simple problems that might be addressed by a doctor if only seeing one didn’t require an ambulance for transportation, or time off work by an adult child, or more taxi fare than remains in the Social Security check, or more effort than seems worth the while.

  The issue is complicated, to say the least. A few years ago, a patient of mine with fifteen major medical problems, including a form of leukemia, decided he didn’t ever want to return to the hospital, do chemotherapy, or try any of other treatments we discussed. But, for weeks after that, he railed and fumed at the prospect of palliative care, because he also wanted very badly to live.

  He wanted to live—just not in the hospital, with poisons in his blood. He was sick and tired of feeling sick and tired. His was a reasoned and reasonable stance.

  NATURE

  When I teach what I call public medical writing, I often quote the first line of a New Yorker essay by the surgeon-writer Atul Gawande, “Letting Go,” which reads, “Sara Thomas Monopoli1 was eight months pregnant with her first child when her doctors learned she was going to die.” Then I ask my students, who are sometimes medical or nursing students but more often doctors, patients, writers, and caregivers of all ages, why Gawande chose to start the essay with such an atypical death.

  If my question is met by silence, I offer an alternate first sentence, asking the group to consider its relative impact: “Joann Stern Smith was ninety-four years old with dementia, advanced heart disea
se, and failing kidneys when her doctors learned she was going to die.”

  Gawande picked the real Sara for his article because she wasn’t supposed to be dying. Because only a hardened heart wouldn’t break at the notion of a young pregnant woman dying. Because that sort of death grabs our attention.

  Gawande’s brilliance notwithstanding, what matters in good writing and what matters in life aren’t always the same. In life, my scenario, not his, is the norm. In a moral universe, that’s as it should be. It’s natural. Joann Stern Smith had a long life, reaching closer than most to the upper age limit for our species. Where we get into trouble is when we use this natural order of things—people shouldn’t die young; dying old is our best option—as a reason not to care and, in medicine, not to provide the best possible care for old people.

  When we think, of course she’s dying, we forgo the thought that, whatever her age, here is a human being in need of care and compassion. Someone like us. But unless that particular human being is their grandparent or parent, people often don’t consider that even if she’s ninety-four and very ill, even if she has advanced dementia, her suffering counts. That her death doesn’t surprise us, that it seems part of the natural order, doesn’t lessen its profound significance.

  When we’ve reached old age, we may be very experienced, but we’ve never died. This process of dying is always new, invariably meaningful. Our words and actions as fellow human beings, as family and friends, doctors and nurses, and as a society matter not only in death but in the life and all the living leading up to that death, regardless of the age of the dying person.

  There is an undeclared war taking place across the United States. It’s a battle between aging and dying that quietly began toward the end of the twentieth century. Now, several decades into the conflict, reports from the field are unequivocal: dying is winning by a landslide.