Our Own Story

   If there's one theme in the past few postings, it's likely one of independence as one ages.  Being suddenly (or slowly) disabled from an accident or a sudden infection is alone life altering; but it is the aging process that more generally shifts one's attitudes from feeling immortal and having to accomplish or acquire much, to that of reflection and, in a sense, living life despite the shortened time.

   Atul Gawande's recent book, Being Mortal (mentioned in the last posting), captures this well, at one point describing what many (or any) of us would feel:  All we ask is to be allowed to remain the writers of our own story.  That story is ever changing.  Over the course of our lives we may encounter unimaginable difficulties.  Our concerns and desires may shift.  But whatever happens, we want to  retain the freedom to shape our lives in ways consistent with our character and loyalties.  This is why the betrayals of body and mind threaten to erase our character and memory remain among our most awful tortures.  The battle of being mortal is the battle to maintain the integrity of one's life--to avoid becoming so diminished or dissipated or subjugated that who you are becomes disconnected from who you were or who you want to be.  Sickness and old age make the struggle hard enough.  The professionals and institutions we turn to should not make it worse.  

   His book details an eye-opening effort to ask the difficult questions of those dealing with Alzheimers or dementia, lack of mobility or the inability to care for themselves...who are you, what do you care about, what makes you happy?  The shift in questioning is simple and, as he points out, right in front of us.  For often the questions asked and the answers given --from the medical field to close and loving relatives-- somehow leave the resident/patient/person out of the picture entirely, as if he or she wasn't there.  This will make you happy, we say:  prepared meals, lots of activities, new friends, a brand new place where you won't fall, doctors and nurses all close by to help (and, as Dr. Gawande points out, because society turned caring for the elderly from a family "problem" to a medical one, the name became "nursing" home).  But from the viewpoint of the person being moved into such facilities, the amenities mean little for they have basically lost everything...their "home" is now a small room with a tiny dresser or closet, often a roommate they know little about and had no say in that choice, a schedule of food and pills and monitoring that for them might seem prison-like, inescapable in time, strength and will.  His book makes you imagine being suddenly removed from all that you knew, your comforts, your neighborhood, your pets, your clothes, even your bills and favorite snacks, all the while those you love stand by you smiling and saying that this is the best thing for you, really.

   Dr. Gawande is well aware that medical needs override many of these decisions, that families and couples are working and unable to afford or don't have the time to provide such full time care.  Mental and physical limitations can also soon fall beyond what a family member can provide.  But our needs and wants are unchanged through it all.  For those no longer able to care to themselves, it comes down to a matter of dignity and of life...of living.

   One such tale is that of Dr. Bill Thomas, an almost self-made physician and farmer who jumped from working an emergency room to directing and running a nursing home.  The change in patients' outlook was startling, the moods among those he saw were depressed and the will to live almost gone.  So why not change things, he thought.  Let's apply for a grant, let's throw out the plastic plants and bring in live plants, plants that have to be cared for in order to keep them alive.  And what about dogs, even cats, and on a cold winter day, what would be better than to hear birds chirping, so why not bring in birds, hundreds of them!  Imagine the nurses and administrators, scoffing and aghast at such a proposal, a proposal that had almost zero chance of being approved by the state.  But Dr. Thomas said simply, why not try?  And the grant was awarded, approval granted.  The results after a two-year extensive study by independent researchers? -- prescription use, especially for psychotropic drugs, dropped by half, drug costs overall fell by 38% and the death rate dropped 15% (all compared to a control group in another nursing facility nearby).  Why?  Said Dr. Thomas, "I believe that the difference in death rates can be traced to the fundamental human need for a reason to live."

   Said Dr. Gawande in his book,  The most important finding of Thomas' experiment wasn't that having a reason to live could reduce death rates for the disabled elderly.  The most important finding was that it is possible to provide them with reasons to live, period.  Even residents with dementia so severe that they had lost the ability to grasp much of what was going on could experience a life with greater meaning and pleasure and satisfaction.  It is much harder to measure how much more worth people find in being alive than how many fewer drugs they depend on or how much longer they can live.  But could anything matter more?

   Stanford psychologist, Laura Carstensen, researched her hypothesis that "how we seek to spend our time may depend on how much time we perceive ourselves to have."  And as Dr. Gawande elaborated:  When you are young and healthy, you believe you will live forever.  You do not worry about losing your capabilities.  People tell you "the world is your oyster," "the sky is the limit," and so on.  And you are willing to delay gratification--to invest years, for example, in gaining skills and resources for a brighter future.  You seek to plug into bigger streams of knowledge and information.  You widen your networks of friends and connections, instead of hanging out with your mother.  When horizons are measured in decades, which might as well be infinity to human beings, you most desire all that stuff at the top of Maslow's pyramid--achievement, creativity, and other attributes of "self-actualization."  But as your horizons contract--when you see the future ahead of you as finite and uncertain--your focus shifts to the here and now, to everyday pleasures and the people closest to you.

   In a related view, this month's issue of Popular Science featured an article on neuroimaging studies of other animals and their brain regions, surprisingly finding areas and cells thought to be exclusive only to humans (one example are "spindle" cells, thought to be important for sensing self-awareness, compassion and empathy).  We share so much DNA with chimps that their blood is interchangeable with ours once blood type is matched.  Macaques share 11 of our 12 brain regions.  And these discoveries are appearing in whales, dolphins, elephants and other animals as well.  Imagine their feelings at being shot at or chased from home or captured and housed in zoos, feelings perhaps all too similar to what our elderly may be feeling.

   Dr. Gawande's latest book is worth viewing if you're anywhere close to approaching such difficult life decisions, that of yourself growing older or of watching your parents grow a bit more absentminded.  His book will shift your perspective a bit, nudge you a bit to the other side's view and perhaps give you a glimpse of what may or may not be the best decision.  It's an important decision for all parties, a lifelong one, but not one that has to be a life ending one.

  Perhaps this issue of animal feelings and elderly feelings and shifting perspectives was better summed up in the Popular Science piece:  In a sense, we're discovering that the search for complex beings like ourselves has been forever pointed in the wrong direction.  Rather than seeking answers in a distant star system, we can find them in billions of years' worth of evolutionary biology.  As for the intelligent aliens we've so longed to meet--they have been right here beside us all along.