She thanked me. Although she was appropriately serious and sad, there was also an energy to her voice that hadn’t been there at the start of the call. Hanging up, I thought, not for the first time, how wrong people were when they said geriatrics was depressing or that having a patient die meant failure for the doctor. I felt deeply sad for Gwen and John, but that’s not the same as depression, which suggests hopelessness and meaninglessness. These moments were hard for John and Gwen, likely among the hardest of their lives, but they were also profound, important, and meaningful.
* * *
Recently, when I sent a condolence note to a friend about her stepfather’s death, I received a long e-mail reply that included this paragraph:
One of the many mysterious takeaway’s from J’s death and gigantic legacy is how it has made me feel terrifically alive and urgent to get more shit done, but also to pause and take time for those who matter and I don’t get to see … In those last days … we all struggled with the protocols and systems around seeing an old man breathe his last breaths with dignity in the midst of [a] Shakespearean drama … Super weird and sad and comical and intense. Luckily my whole family circled the wagons … We all camped out in my Mom’s apartment for the week to help manage the chaos and hold my mother up. So of course there’s that other mystery, which is that it’s been a lot of fun with loads of laughs. When else do I get so much prolonged time with my family without anyone feeling like there’s another place to be, other responsibilities to maintain? We were all just there. Sitting. Eating. Answering the door. Loading and unloading the dishwasher …
In life, different people and families value different things; in death, they tend to value the same few fundamentals, and one of the surprises of an expected and mostly comfortable death at life’s natural end is the license it gives everyone to put those fundamentals first.
John didn’t die that night or that week, though he did die a few months later, in hospice.
DEATH
If we had the courage to think and reflect about life and death, we would raise our children differently … we would make death and dying a part of life again.1
—Elisabeth Kübler-Ross
14. STORIES
In an essay titled “On Sixty-Five,”1 Emily Fox Gordon said she’d really begun to feel her age. But in the next paragraph, she wrote: “I hasten to add that though my muscles may be weakening and my joints stiffening, I’m not infirm. I’m as vigorous as I ever was, and reasonably healthy.” A young person reading that passage might logically think: Hold on, now, you can’t have it both ways: either you’re weak and stiff or you’re vigorous. Which is it? Fox Gordon offered similar contradictions about her cognition. “Mentally I’m quite intact, though my memory, always bad, grows worse.” The point of the essay was that her body and life had changed in significant ways, and also, she seemed to lack many of what she took to be the defining manifestations of old age. Her acquaintances agreed with that assessment: “People tell me I seem younger than my years.” By which, they presumably meant she still seemed like a “normal” human being.
Here are the facts: One, Fox Gordon was over halfway through her seventh decade, an “old person” by accepted definitions throughout most of human history and legally in the United States—she qualified for retirement, Social Security, and Medicare. Two, her body and mind had changed with age, mostly for the worse. Three, in her estimation and in the opinions of people who called her young-looking, being old wasn’t half bad. The only logical conclusion one can draw from these facts is that there’s a disconnect between the reality of old age and our beliefs about it—at least for the young-old.
People acknowledge their transition from adult to elder at different ages. Approaching her eighth decade, Doris Grumbach wrote: “This is different. The month at seventy seems disastrous, so without redeeming moments.”2 The British book editor Diana Athill, looking back at her younger-old self from ninety, had a similar reaction: “All through my sixties I felt I was still within hailing distance of middle age, not safe on its shores, perhaps, but navigating its coastal waters … Being ‘over seventy’ is being old: suddenly I was aground on that fact and saw that the time had come to size it up.”3 By the summer of 2018, both Athill and Grumbach were one hundred years old. Both had published books in their nineties and essays in their hundredth year. If this qualifies them for the “exceptional elder” mantle, it also proves that seventy is not, by definition, an unmitigated disaster.
It is different, however. All ages are. At eighty, Penelope Lively described her aged self as almost becoming a new person:
This someone else, this alter ego who has arrived, is less adventurous, more risk-averse, costive with her time … There is the matter of the spirit and the flesh, and that is the crux of it: the spirit is still game for experience, anything on offer, but the body most definitely is not, and unfortunately calls the shots.4
The body is also what most people respond to, whether looking at someone else or at ourselves. Twenty-one years before she died at the age of ninety-four, Doris Lessing also referenced the growing distance between her body and self: “The great secret that all old people share is that you really haven’t changed in seventy or eighty years. Your body changes, but you don’t change at all. And that, of course, causes great confusion.”5 Comments like these, common as they are among both great writers and my patients, make me wonder whether the greatest challenge of elderhood is overcoming our tendency to look at old age and see only bodily decline, forgetting that inside the body is a fellow human being.
At eighty-two, May Sarton wrote: “I have begun this journal at a time of difficult transition because I am now entering real old age. At seventy-five, I felt much more able than I do now … forgetting so much makes me feel disoriented sometimes and also slows me up. How to deal with continual frustration about small things like trying to button my shirt, and big things like how to try for a few more poems. That is my problem.”6 Reading this, I picture a small, white-haired woman moving slowly. But also present in that passage are emotions and experiences I share: I, too, was more able seven years ago, in my forties; I, too, now forget things I once would have remembered; I, too, have things I’d like “to try for” in the remainder of my life. Look closely, and we are more similar than different.
By age ninety, Diana Athill lamented that “dwindling energy is one of the most boring things about being old. From time to time you get a day when it seems to be restored, and you can’t help feeling that you are ‘back to normal,’ but it never lasts. You just have to resign yourself to doing less—or rather, taking more breaks than you used to in whatever you are doing.”7 Even here, there is universality. Although old age is a particular state, replace being old in the first sentence with being pregnant or being injured or being overworked and the rest of Athill’s words could describe any of us. Old age doesn’t change our normal human responses.
Still, elderhood is different, and not just because of changes in the body and brain. “I’m ninety-three,” wrote Roger Angell, “and I’m feeling great.”8 There was, however, also this: “It shouldn’t surprise me if at this time next week I’m surrounded by family, gathered on short notice to help decide, after what’s happened, what’s to be done with me now.” Illness and death loom more prominently in elderhood than in earlier life stages. The tragedy of old age, wrote the Pulitzer Prize–winning geriatrician Robert Butler nearly fifty years ago, is “not the fact that each of us must grow old and die, but that the process of doing so has been made unnecessarily and at times excruciatingly painful, humiliating, debilitating, and isolating.”9
For one month in 2018, I conducted a thought experiment. Everywhere I went, I imagined the people I saw without hair dye or implants or comb-overs. The more I looked, the more I found—after all, men’s first gray hairs generally appear at thirty, and women get their first, on average, by thirty-five. People from all ethnic groups. People who looked rich and people who looked poor. People who were adults, midd
le-aged, senior, old, elderly, and aged. Everywhere I looked (including in the mirror), I saw people pretending to be something other than what they were. How can it be that we have created a society where a majority of adults and elders feel ashamed of their basic identity? And if we are pretending to be something we are not, how can we be surprised or disappointed when others disparage what we are?
Imagine if everyone who was middle-aged or old looked middle-aged or old. Imagine if when we looked at our bus drivers, nurses, world leaders, teachers, rock stars, investment bankers, caregivers, cops, doctors, tech executives, grocery clerks, real estate brokers, lawyers, manicurists, and favorite actors, we saw what they really look like, who they really are. Imagine gray, white, and absent hair signaling the completion of youth and the ascent of maturity. Imagine if all those gray-, white-, and absent-haired people did all the things they already do. Imagine we liked, loved, respected, admired, and were inspired by them as we already are, and when they got older still and needed some help from us, we offered them a world and a worldview that said: We still see you, and we still like, love, respect, admire, and are inspired by you, both for who you were and for who you are, a person completing the full arc of a human life. Imagine old people seeming less “other” and more “us.”
Most people want to look good, but when we define good as young, we set ourselves up for failure. We tell just one of the many stories of old age. Life offers just two possibilities: die young or grow old. The latter is the better option for most people, but it’s not nearly as good an option as it could be. As go our hair color and health care dollars, so go our lives. If we pander to prejudice, we should not be surprised to find ourselves invisible, overlooked, or discarded.
CODA
It was my intention to write with a polemic voice.1
—Terese Marie Mailhot
OPPORTUNITY
I have devoted as much of this book to history, literature, philosophy, anthropology, sociology, and stories as to science. The position that science will solve our species’ greatest sources of anxiety and anguish already has vocal, powerful advocates. I wanted to add another perspective, to show that when we take a single approach to a complex challenge, we sacrifice not only accuracy and truth but opportunities to make life more of what we hope for and need and less of what we fear and dread.
A good life, like a good story, requires a beginning, a progression, and an ending. Without those defining elements, it feels partial, even tragic; it lacks shape, purpose, and meaning. The end may be hard and sad, but even when we don’t want a story to end, the best ones leave us with a sense of completion and satisfaction.
The left-brain fixers among us offer only instruments. Sometimes these are lifesaving or life enhancing; other times, their unintended consequences overshadow any benefits. Without due diligence about who chooses the questions and tools, who benefits, and who might be gravely harmed, what appears to be progress can be anything but. Science and technology can only ask and answer certain sorts of questions. Those instruments, although now considered synonymous with progress in both medicine and life generally, will become socially and morally responsible only when they are paired at the outset with equal consideration of their origins, intent, and impact on people of all ages and backgrounds.
Events are judged not on their entirety but on their moments of peak intensity1 and on their endings. And what is life but a long, messy, awful, wonderful event? Elderhood is life’s third and final act; what it looks like is up to us.
ACKNOWLEDGMENTS
I owe a huge debt to:
The many writers and scholars quoted herein, not only those who have done so much for old age, but also those whose brilliant brave work taught me about writing, thinking, difference, and life. Particular thanks to Claudia Rankine, Ursula K. Le Guin, Andrew Solomon, Mary Beard, Matthew Desmond, and Maggie Nelson for showing me what was possible.
Victoria Sweet, for that September phone call when she gave me the advice that changed my approach to this book and helped me make it so much more of what I wanted it to be.
The medical institutions that made me the doctor I am: Harvard and, especially, UCSF. As two of the best in the country, they know their strengths. If in these pages I sometimes point out their opportunities for improvement, it’s only because I know they can lead the nation to a better, more just, inclusive, and effective medical system.
My writing group—Catherine Alden, Natalie Baszile, Susi Jensen, Kathryn Ma, Edward Porter, Bora Reed, and Suzanne Wilsey—for the enduring pleasure of their friendship, good food, wise advice, and gracious indulgence of my deviation from fiction into writing the real.
The MacDowell Colony, where a years-old mess of documents and files was miraculously and almost instantaneously transformed into the first real draft of this book.
Bill Hall, whose remarkable achievements in medicine, unique erudition, widely learned lectures, and endless support have meant more to me than he appreciates.
David Shields, who told me the “weird” stuff I wanted to do in my writing was interesting and important.
Katy Butler and Sunita Puri, fellow travelers whose support always cheers me.
The editors who published parts of this book (before I knew that’s what they were) in the following publications: the New York Times, the New England Journal of Medicine, the Lancet, Health Affairs, the Washington Post, Academic Medicine, and New England Review.
My patients, past, present, and future. The word doctor comes from the Latin docere, but any physician who has practiced medicine knows we learn as much from patients as they do from us. I cannot thank mine enough for entrusting me with their care.
My agent, Emma Patterson, and my editor, Nancy Miller, for their unwavering confidence and patience over the many years this book didn’t get started, then the couple of years it didn’t get finished, and their help once it was on its way.
My father, who taught me so much, directly and indirectly, and whom I miss.
My mother, always my biggest fan, whose elderhood I aspire to emulate and fear I won’t.
Jane, especially and always.
NOTES
Conception
“never just a body” Featherstone, M., & Wernick, A. (1995). Images of aging: cultural representations of later life. London, UK: Routledge.
1. Life
over 40 percent of hospitalized adults AHRQ Reports: Healthcare Costs and Utilization Project. (2010). Overview statistics for inpatient hospital stays.
3. Toddler
History
“the book for the transformation of an old man into a youth” Magner, L. N. (1992). A history of medicine. (35). New York, NY: Marcel Dekker.
variability of old age Plato, Grube, G. M. A., & Reeve, C. D. C. (1992). Republic. Indianapolis: Hackett Pub. Co.
“end aging forever” Buhr, S. (September 15, 2014). The $1 million race for the cure to end aging. TechCrunch; De Grey, A., & Rae, M. (2007). Ending aging: The rejuvenation breakthroughs that could reverse human aging in our lifetime. New York, NY: St. Martin’s Press; McNicoll, A. (October 3, 2013). How Google’s Calico aims to fight aging and “solve death.” CNN; National Academy of Medicine. (October 19, 2015). Special session: innovation in aging and longevity. Special session of the Symposium on Aging at the NAM Annual Meeting, Washington, DC.
similar stipulations for older adults Span, P. (April 13, 2018). The clinical trial is open: the elderly need not apply. New York Times.
exercise, diet, sleep, and management of constipation Mulley, G. (2012). A history of geriatrics and gerontology. European Geriatric Medicine. 3(4), 225–227.
“Apostle of Senescence” Birren, J. E. (2007). History of gerontology. In Birren, J. E. (Ed.), Encyclopedia of Gerontology (2nd edition). San Diego: Academic Press (Elsevier); Peterson, M., & Rose, C. L. (1982). Historical antecedents of normative vs. pathological perspectives in aging. Journal of the American Geriatrics Society. (30)4, 292.
moderation and personal responsibility Walker,
W. B. (1954). Luigi Cornaro, a renaissance writer on personal hygiene. Bulletin of the History of Medicine. 28(6), 525–534.
Francis Bacon studied long-lived people Peterson, M., & Rose, C. L. (1982). Historical antecedents of normative vs. pathological perspectives in aging. Journal of the American Geriatrics Society. (30)4, 292.
he was right on all counts Carp, F. (1977). Impact of improved living environment on health and life expectancy. Gerontologist. 17(3), 242–249; Fontana, L., & Partridge, L. (2015). Promoting health and longevity through diet: from model organisms to humans. Cell. 161(1), 10–118; Gravina, S., & Vijg, J. (2010). Epigenetic factors in aging and longevity. Pflügers Archiv—European Journal of Physiology. (459)2, 247–258; Terracciano, A., Löckenhoff, C. E., Zonderman, A. B., Ferrucci, L., & Costa, P. T. (2008). Personality predictors of longevity: activity, emotional stability, and conscientiousness. Psychosomatic Medicine. 70(6), 621–627.
Discourse of the Preservation of the Sight Susan, A. G., & Williams, M. E. (1994). A brief history of the development of geriatric medicine. JAGS. 42, 335–340.
Struldbruggs Swift, J. (1953). Chapter 10. Gulliver’s travels, book 3. (234–249). London/Glasgow, UK: Collins.
“progressive hardening of all fibres of the body” Schafer, D. (2002). “That senescence itself is an illness”: a transitional medical concept of age and ageing in the eighteenth century. Medical History. 46, 525–548.
“old-age infirmity is no illness” Parker, S. (2013). Kill or cure: an illustrated history of medicine. New York, NY: DK Publishing.
“creating respectable cowards” Cole, T. (1992). The journey of life: a cultural history of aging in America. Cambridge, UK: Cambridge University Press. (191).
descriptions of dementia Day, G. E. (1849). Practical treatise on the domestic management and most important diseases of advanced life. Philadelphia, PA: Lea and Blanchard.
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