Aging Thoughts: Control and Death

As an aging American male, I long ago learned that, although not necessarily a clinical “control freak,” I certainly do like to control people and situations in my life. This applies to family members, those with whom I work and direct when in leadership positions, and even the driver in front of me who is going much too slowly.

One of the consequences of aging is that we are forced to accept the fact that we are no longer as “in control” as we once were.  This applies to our bodies, which no longer respond to our commands as they once did, and to our minds, which, as early as age 50, challenge us with something known as “delayed recall.”  That is a nice way of saying that we can’t remember names, places, words, or sometimes even why we just entered a particular room in our house.

And that can be scary. I am thankful that I can still draw the numbers and the hands on the clock face that my insurance company nurse asks me to do once a year during her home visit. That test has a name, but I can’t remember what it is.

The older we get, the more seriously we must take the question of control.  I accept that I am already losing some control of my physical self; I can no longer jog 5-8 miles at a time as I once did; that stopped over twenty years ago.  Now I have back issues with two lumbar discs already fused, and a surgeon willing to fuse several more.  I am trying to avoid that with physical therapy and walking a mile almost every day, even with some leg pain.

A greater fear is losing control of my mental self and no longer being able to read or write as I do now. My maternal genetic history is pretty good, with my grandmother dying at 89 and others of her family in their nineties—with no dementia.  Of course, “back then” the world wasn’t as crowded and the air, soil and water were much less polluted. I will pass over and leave unmentioned my paternal history of circulatory problems, heart attacks and strokes.

A New Take on Aging and Medicine

Aside from the concerns listed so far, my question now, pondered by others of my generation, is simply: can I have any control over how I face death?  One medical professional thinks the answer is yes.

Dr. Atul Gawande, author of Being Mortal: Medicine and What Matters in the End (2014) is an unusually accomplished man. In addition to practicing surgery at Brigham and Women’s Hospital in Boston and teaching at Harvard Medical School and the Harvard School of Public Health, Gawande is a staff writer for New Yorker magazine and has won a MacArthur Fellowship and awards for his science writing.

The argument of Being Moral is simple and important. Many older people, when facing death, are not as excited as their physicians and family are about trying to postpone death. People want to avoid suffering, but they also want to know that their life has mattered. The job of physicians, Gawande asserts, is not only to “ensure health and survival” to the extent reasonable, but also to “enable well-being.” In my Catholic youth, that was called “a happy death.”

People in the final stages of life usually recognize that fact. Those on the verge of “passing away” want to end their journey on earth with family and others to whom their life matters rather than drugged and on machines in order to gain a few more days or months. But this isn’t always easy.

Gawande’s book is replete with many compelling stories of patients, friends, and even his father, all of whom took the final journey. It is also a history of how the modern medical community often sadly (mis)treats those they desperately and sincerely want to help.

The author tells the interesting history of how the first “assisted living” facilities were begun by a woman in Oregon to serve as an alternative to the hospital long-term care wards where patients were expected to die.  Her buildings were designed to give people greater control over their final months, even to the point of having apartment doors that locked—so nurses couldn’t come in every few hours to disturb sleep. These places initially did all they could to keep people active, even if that meant hiring therapists and others to help residents stay engaged in life.

Later, as a way of saving money for their owners by cutting “extra” services, most “assisted living” facilities adopted many practices of less expensive nursing homes, which tend to follow the medical model of the hospital. In that model, doctors and nurses want to “fix” us. That is their job and their commitment. If they can’t do that, they can lose interest, Gawande tells us.

Being Mortal also gives readers a very honest account of how difficult it can be for patients to accept the fact that it is truly time to let go of the fight and turn to hospice or home care.  For families, this requires “hard conversations,” on which he has a chapter.

However, the larger and most important message of Gawande’s book is that people should be allowed to have as much control over their departure as possible. He cites the cases of a number of people who, near death, were allowed to go home and live the life that had meaning for them for months longer. One of them, his daughter’s music teacher, was able to continue her lessons for students for weeks after entering home hospice.  She was able to say goodbye to them in the way most meaningful to her, and to her students.

Although we are asked, as we age, to gracefully give up some control, it appears to be good physical and spiritual practice not to give up all control over those things that matter most.

We need, writes Gawande, to “achieve a sense that [our] life is complete.”