A Tale of Two Elders

Concern for elderly relatives and friends has been heightened during the coronavirus pandemic.   In the last month, I have visited two nonagenarians:  one was in the assisted living portion of a large multi-level care facility; the other, in her own home.  In both, frequent hand washing or sanitizing by visitors was done.  The assisted living facility visit required a mask and at least six feet of distance between us at all times.  The second nonagenarian refused to wear a mask, and we ate several meals together, maintaining some interpersonal distance.  Both visits were incredibly special, and I am grateful that we all continue to be well.

Thanks to Andrew Cockburn’s “Elder Abuse” article in Harper’s Magazine, I have formulated some important questions to ask about the care facilities for elderly that abound in our nation.  These should be helpful for relatives and friends who are either in long-term care facilities, or contemplating moving into one:

  1. Are you/will you be close to concerned relatives or friends, or far from any potential visitors?
  2. How often are visitors allowed?  What are the rules, including during a pandemic?
  3. Who owns the facility?  Have there been any fines levied for substandard care/other problems?
  4. Is the facility in a state that has legislation holding harmless the facility during this pandemic?
  5. Does the state where the facility is located have an ombudsman for senior care?  Is that office functioning now?
  6. Is there a local newspaper/reporter who publishes on senior issues?  Read their articles, and consider sending an email to interact with the writer of any article on elder concerns.  Building bridges in the community is important.
  7. Not to put too fine a point on it, but who will be paying for the care?  The “Elder Abuse” article points out that nursing homes strive to obtain the “right mix” of Medicaid and Medicare patients.  A COVID-19 diagnosis can benefit facilities monetarily; but then, so can discharging Medicaid patients in an effort to open beds for patients with higher-paying Medicare benefits.

Using data from the World Health Organization, Cockburn reports the differences between, inter alia, the United States and Greece, in terms of elderly casualties from COVID-19.   The United States has 515 nursing home beds per 100,000 population; Greece, 15.  The United States has 39 COVID-19 deaths per 100,000; Greece, with the “largest proportion of elderly people in Europe,” has two deaths per 100,000.  The author suggests, “One might almost conclude that the death toll that has so traumatized and destabilized much of Western society in 2020 was not wrought principally by the coronavirus, but by nursing homes.”

The nonagenarians I recently visited are both Americans.  The masked 93-year-old in an assisted care facility has been restricted from speaking with other residents he meets in the hallway or when he walks outside on the well-manicured grounds.  He has spent months having meals delivered to his room where he eats alone.  He spends thousands of his retirement dollars per month, but cannot be said to be happy with his purchase.  The other nonagenarian I visited lives alone.  She has not seen the inside of a store since March, because other people shop for her, using lists she has provided.  Her budget is significantly smaller than her counterpart described above, but she is rich in relationships.  For her birthday this summer, she received 123 cards. 

The Greek model of elder care seems clearly a better choice. Americans could do this — without importation tariffs.

Atul Gawande’s Look at Mortality

I was invited to write a review of the book Being Mortal by Atul Gawande recently. While not a Christian book, it addresses end of life issues of interest to all involved with bioethics. This is part one of two.

Evidence of humankind’s tendency to avoid the inevitable surrounds us in our culture. Burgeoning numbers of technological and surgical enhancements, from Botox to Nano therapy, promise us long, beautiful, pain-free lives. A recent headline shouted “The First Person to Live for 1,000 Years Is Probably Already Alive!” Transhumanism believes genetic technology will indeed eliminate death altogether. American culture in particular seems to reflect a people who have an uncanny ability to live as though the aims of the transhumanists have already been accomplished, and we will never die.

Against that backdrop, the blunt title of surgeon and Harvard Medical School professor Atul Gawande’s newest book, Being Mortal, seems more striking. Modern medicine has made tremendous advances in the elimination of once-deadly diseases and has allowed humans to live longer lives. But Gawande’s premise in writing this book reflects the idea that the very gifts to humanity that modern medicine brings also create a direct conflict with the reality of our own mortality. Many may long for a life free of death in this world, but our intellect, experience with family and friends who die, and (for Christians) words like Hebrews 9:27, “and just as it is appointed for man to die once, and after that comes judgment…” temper any delusions otherwise. Gawande celebrates the advances of medicine, but also laments that, in a healing profession designed to find a problem and fix it, medicine may be worsening the lives of the very patients it seeks to help. At some point, the fix may not be worth the cost as it butts up against the inevitability of death. We crave independence, as human beings and, indeed, as modern Americans, but our own mortality is its greatest threat. It was once thought that a speedy death was not to be desired…the Book of Common Prayer includes an explicit petition to avoid one, presumably in order that we may have time to make our peace with our God and others before we die. In fact, until recent years, a “fast death” was far more likely to occur than it is today, with technology that can sustain life beyond what could have been imagined a few generations ago. We are more likely to die over an extended period of time today, and that is rarely answers our prayer, but feeds our fear. We do not fear death so much as we fear the loss of the life we want to lead, which is made manifest in in a slow death.

Gawande does an extremely effective job describing the physiological effects of aging…the losses that begin before we know they have happened and that reach an inevitable end point when we die. Our ability to cheat death through whatever measures we choose must be reconciled with these realities, in a chapter labeled simply, “Things Fall Apart.” He then goes on to connect the losses of aging with the loss of our independence, which is considered the most painful loss of all, and then begins an extended critique of our society’s efforts to look after the increasingly-dependent as these losses mount. The modern nursing home, which has “…come a long way from the firetrap warehouses of neglect they used to be,” still are found lacking. “[I]t seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.” He is critical of the modern system that allows the safety of patients to trump all other concerns, including their sense of purpose, their freedom, and which seems to assail their very dignity as humans.

Assisted living, which is a concept that has been extremely popular and profitable (at least as indicated by the mushrooming numbers of such facilities being constructed where I live), offers, in Gawande’s view, some improvements in the life of the increasingly-dependent over the nursing home model. These facilities certainly seem to assuage the greatest concerns of the children of their residents, perhaps the greatest reason for their appeal and success. But these, too, seem to view the safety of their residents, such as whether or not they get every one of their medications, or whether they can avoid foods and activities that could lead to harm, over their mental and emotional health. He laments a “life designed to be safe but empty of anything they care about.”

Gawande goes on to describe, in a chapter called “A Better Life,” what could improve these models. He illustrates the way nursing home and assisted living could work for their residents, through stories of those who have actually done so. These are stories of facilities that offered enriched environments, that stretched the conventional notions of what was safe and seemed appropriate for their residents to allow them to live lives more in line with what they wished. These stories were notable for both their remarkable effectiveness and, sadly, their rarity. While specifics of public policy are not explicitly addressed, it would be intriguing to see how Gawande would suggest these stories be applied to the broader context.

(Part 2 of this review to follow)