As a speech pathologist, I started working in hospitals and nursing homes when I was twenty-four. Although I “knew” that everyone is subject to old age, sickness and death, somewhere deep down I still believed that people who were old and sick had somehow caused their own predicaments. I remember guessing that two-thirds of people in nursing homes were there because they had smoked. Whether or not that was true, over time I have seen the constant procession of beds emptying and being refilled, and I understand that we are all part of this endless parade of arising and passing away. My tendency to judge people has diminished. I no longer fault people for growing old and being sick. Other lessons about impermanence have emerged for me as well.
The General is 104 years old. He graduated from West Point in 1926, served in the Philippines and North Africa before World War II, and became one of the first American POWs when Rommel’s troops overran his unit. He was married for seventy years and has two sons and many grandchildren. Last year he had pneumonia, and his doctor suspected that his difficulty with swallowing put him at risk for getting it again. I was sent to evaluate and strengthen his swallowing ability.
I found the General in his room in a wheelchair, bald, wrinkled and frail. NPR news was blaring forth from a radio he held up to his ear, and a scotch on the rocks sat nearby. I introduced myself and told him why I was there. “I don’t have any difficulty swallowing,” he declared, “thank you very much.” I replied, “That might be true, but your doctor wants me to check.” He reiterated, “There’s nothing wrong with me.” He took a sip of his scotch and coughed. Yep, I thought, he’s clueless.
Realizing I wasn’t going to get anywhere without connecting to this man’s fiercely held sense of dignity, I stopped and looked around the room. Noticing some military memorabilia, I remarked, “So, I see you were in the army. What do you think about this war in Iraq?” A lengthy discussion ensued. Eventually, I reapproached the topic of pneumonia. “Our physiology is such that if there is a weakness in swallowing, things can go down the wrong pipe and end up in our lungs, causing pneumonia,” I explained. He listened attentively. “Yes,” he finally said. “I can see how that might happen.” From then on, it wasn’t hard to get the evaluation done.
I treated the General for a few weeks, and he improved enough that a recurrence of pneumonia seemed unlikely. Each session included much conversation. He was delighted to find out that my husband, Doug, and I fly a small helicopter. He began calling me “The Helicopter Lady” and told me how much he enjoyed our work together. We compared spouse stories and laughed a lot. I was struck by his ease in life. In spite of physical disabilities, sensory loss and an acknowledgment that he had few years left, he gave an impression of wholeness and strength. I compared my first view of him as a debilitated little old man to my view after I got to know him—a vital, dear human being who happened not to have much hair, couldn’t walk or hear very well, and whose skin wasn’t so supple. I saw how my judgments about outer appearances can shift. I also saw that as I can sometimes stop taking my own wrinkles so personally, I can also stop defining others based on their aging bodies.
One day I told the General about a joke Doug and I have between us. Whenever I’m gone Doug teases me that he has the dancing girls over to visit, and when he’s gone it’s the dancing boys for me. Doug had just called, and I said I’d be sure to kick out the dancing boys before he arrived home. The General laughed, looked at me for a few seconds, and then said, “You know, I could be a dancing boy.” I had no doubt.
Working with the General was easy despite his advanced age. Life seems “just” when one has lived fully and is declining toward death with little suffering, especially if he or she expresses warmth and humor, is aware and retains cognitive capacity.
It was much harder working with George. Although in his mid-eighties, George was tall, handsome and looked much younger. A retired professor of Japanese history, he had a middle-aged wife and two daughters still in college. He was slowly being consumed by a neurological disorder that caused quadriplegia, slurred speech, painful limb contractures, cognitive impairments and difficulty swallowing. In order to help George maintain swallowing ability, I treated him for many months. Eventually swallowing became impossible, and he died of pneumonia.
Every time I saw George, I experienced a little gasp of internal dissonance brought on by the discrepancy between how he looked—still relatively young and strong—and the reality of his contracted helplessness. I also lamented that he was being taken from his family when he “should” have still been there with them. Not fair, my mind protested when faced with sickness like George’s. How awfully wrong.
George loved Kyoto. One day I asked him, “When was the last time you visited Kyoto?” “In reality,” he asked, “or in my dreams?” Startled, I replied, “Either way.” “I was there this morning,” he said with a smile, “walking down a back street to see the old man who sells wood carvings.” George’s ability to sustain happiness despite the mounting losses of his terminal illness spoke to a level of acceptance I had not dreamed possible. I remembered that accepting how things are is always possible, and with that, I was free simply to be with George, sharing in his happiness.
For much of my life, death seemed fearsome to me, and impossibly sad.
When patients are dying, I sometimes feed them or clean and moisten their mouths. One morning I entered Lillian’s room to check on her. The mother of a friend of mine, Lillian was in the final stage of Alzheimer’s. Customarily during my visits, Lillian wouldn’t remember me and would insist that I sit on her bed, apologizing that she couldn’t fix me something cool to drink. Classical music would be playing. Lillian would take my hand and, with rhapsodic appreciation, say, “Listen to that.” This day, as I prepared to clean Lillian’s mouth, I realized that she was actively dying. I called the nurse and then simply stood by her. She was on her side, face and hands relaxed. Her breathing slowed. Then, after one out-breath there was a pause, followed by a definitive, smaller exhalation as her body relinquished its last bit of air. There was nothing else to do right then but love her. Into the silence I whispered: “May you be safe, peaceful, completely surrounded by love.”
I could see the pulse in Lillian’s neck, still strong and steady. I knew that her pulse would soon end, and I could feel my body shake with the recognition of life ebbing. Her heart continued beating for several more minutes. Then it began to flutter. The fluttering became more and more faint. Watching her neck was like listening to the ring of a meditation bell slowly fading away. I couldn’t tell exactly when the fluttering ended.
Beyond experiencing a little of her graciousness, I had not known Lillian well. I was awed by the sense that something had transcended the boundary between her and me, creating an unbreakable bond. Despite my sadness in seeing her die, being with Lillian was a joyful gift that made the world feel entirely on track. I now belong to life with a little more ease for having witnessed this ordinary and gentle death.
Old age, sickness and death form the backdrop to each day in a nursing home. I’ve learned that old age does not change the essence of who we are; that sickness, no matter how horrible, can be met with acceptance; and that death can be as easy and natural as the outgoing tide. There are a couple of games I use to help me accept these processes of impermanence in my life and in the lives of my patients. One is to picture the elders as they might have been as children and younger adults; this allows me to see beyond physical form to deeper aspects of identity. Another game, which helps me let go of fear, is to sense the lack of attachment I have to the time that existed before I was born and then to ask myself why I should feel any grief at all for the time that will come after my death.