The Normalization of Aging and How To Make It Matter
Wise lessons from Sacks and Gawande
Posted Sep 26, 2015
The research evidence that keeping our minds and bodies active can both increase and enrich the number of years we live is building steadily, and is as near to fact as we need to take it on board. (See how dancing is a life extender here). Then there are those people we know ourselves; a great-grandmother still living independently, playing bridge with a group of friends twenty years her junior, and telling her great-grandchildren stories of her childhood in the roaring twenties. On the news we see the centenarian who runs marathons, frustrated with himself because it took him longer than last year. Most of us can’t run marathons now, and certainly don’t expect to when we’re 100, but we might have a sneaking hope—if we ever allow ourselves to think about it—that we’ll be still healthy enough in mind and body to enjoy life into our eighties and nineties. If, from the optimistic stance of our healthy younger self, we could make decisions for our end, many of us would likely opt to live for as long as we are healthy enough to enjoy it, at least some of the time.
Although cancer cut short his life by a few years, this was definitely true of Oliver Sacks. When he died on August 30th, 2015, at the age of 82, the people who had worked with him for many years conveyed the sad but not unexpected news in their newsletter, telling his friends and followers that he spent his final days “doing what he loved—playing the piano, writing to friends, swimming, enjoying smoked salmon, and completing several articles.” Only two weeks earlier he had published an essay, “Sabbath,” in the New York Times. His closing paragraph was perhaps his public goodbye. “And now, weak, short of breath, my once-firm muscles melted away by cancer, I find my thoughts, increasingly, not on the supernatural or spiritual, but on what is meant by living a good and worthwhile life — achieving a sense of peace within oneself. I find my thoughts drifting to the Sabbath, the day of rest, the seventh day of the week, and perhaps the seventh day of one’s life as well, when one can feel that one’s work is done, and one may, in good conscience, rest.” His remarkable autobiography On The Move: A Life (see my book review here), was published in April, and there are more books, as yet unpublished, waiting in the wings.
Oliver Sacks had ample warning that he would be unlikely to see his 83rd birthday, and he made the most of every day he had left. Of course he was no ordinary man, and it is unlikely that many of us will be as productive in our last days, especially if we are suffering pain and discomfort, as Dr. Sacks may well have been. Nevertheless, we can take some valuable lessons from the way he spent his final months; perhaps lessons even more valuable than the many we have learned from his books and essays on the human condition.
Sacks was not a religious man and had no expectations of an afterlife, other than what he left on earth in his writings and in the memories of those still alive. We all know that death is inescapable, whether or not we believe there is more beyond, yet for me at least, and I expect for most of us, when we are generally in good health and a long way from our mid-eighties or whatever the latest statistics tell us the life expectancy for our sex and socio-economic group is, this biological fact is amazingly difficult to grasp. But grasp it we should, sooner or later, at least once we hit fifty or so! Not in order to feel depressed and grim about it, but rather to normalize it, and perhaps reduce the fear that often accompanies thoughts of physical and mental deterioration.
Seventy percent of deaths in the Western world occur after the age of 65, so if you are way younger than this, as most readers of Psychology Today are, you probably have too many other things to enjoy and worry about, and that’s how it should be. But even you will likely one day have to face the aging and death of your grandparents, and then your parents. Here’s the thing; living well until the end is easier to do if the central character has the right sort of support and understanding from the people he or she loves. Oliver Sacks died at his home, surrounded by his close friends and family. That’s how most of us probably hope to die, and seventy years ago most deaths did happen at home. But today 80% of people die in hospital or another institutional setting. Sometimes this is the best place; a hospice for example when the person needs specialist care to make their last days bearable, or a specialist facility when dementia has taken their mind and personality before death, but in many cases with the proper forward planning and attitude, a home death would be quite possible. Just as important is that period at the end of life, when we are wearing out. It is mind-blowing that with the help of higher standards of living and medical advances many human cultures have succeeded in extending their life expectancy so dramatically; in tne US by 35 years since 1900. Today the last child in a family is born to younger mothers than in the past; in the early 1900s a mother’s last child was born near menopause (adding to the chance of her premature death). So by the time we are fifty, all our kids are over twenty and we potentially have thirty-five or more years to live. No wonder there are fewer and fewer multigenerational families living in one house! Indeed, in today’s world many older people don’t want to live with their children (and would rather these adult kids didn’t live with them!) so growing old with family and friends around no longer means all living together. What many seek now is independence well into old age, perhaps with a partner, or in a retirement village where there are others of the same generation to share interests. But a close relationship with family and friends is still of utmost importance, and the older we get the more often we need family close by.
Atul Gawande in his book Being Mortal: Illness, Medicine and What Matters In the End, makes a strong case against the over-medicalization of aging and dying, and believes that a better approach is to train health practitioners, and especially general practitioners, how to assess the healthy elderly and provide the low-cost, humane care and advice that will help them live the last years and months of their lives as safely and contentedly as possible. These “interventions” are often as simple as ensuring their feet and toenails are cared for so they are less likely to fall, that they have an adequate diet, that they have regular contact with people who enjoy their company, and that their home is adapted to make their lives easier. This last is something that is best done by the elderly themselves, before they get too old to manage such an upheaval. Families who do their best to assist with this without taking over and trying to force their own opinions and decisions on their parents or grandparents about what is best (for their parents or for them?) are the five-star families to have.
And this leads on to one of Gawande’s most important points: what matters in the end can only be discovered by asking the elderly person. Their children, or even their partner of forty or more years, may not know what matters to them right now, at this point in their lives. We all know that what matters to us can change as we go through life, and we can’t always predict ahead of time what will really matter when we are old. Gawande discusses this in the context of medical interventions offered to elderly people, sometimes with terminal illnesses, but more commonly when they have numerous “medical” problems as a result of old age; that is, the gradual wearing out of their body organs. The discussion the family should have with their elderly relative is about quality of life—what matters to them and how much are they willing to risk and suffer (in terms of medical interventions) in order to make this possible? For some it may be that if they can be made well enough to be around for their grand-daughter’s wedding, that is what really matters; for others it will be that if they can still listen to music although bedridden and unable to see well enough to read, that is what really matters; and for others it may be that if they can’t sit at the table every night and eat with their family and join in the conversation, then it is time to go. Some people may even want everything possible done to keep them alive, whatever the risks and possible consequences. Not an easy discussion, and one that may need to be repeated, given that what really matters in the end will change as the body becomes more debilitated and pain increases, and as the mind dims.
For Oliver Sacks, what really mattered in the end was to keep writing, listening to his music, eating his favorite foods and to keep loving and being loved by his partner and friends. This he achieved, such that his legacy is that to the very end, he enjoyed a life well lived. And as I am sure he would have said, if he could do it, so can we all.