THE DWELLING PLACE / CENTER FOR HEALTH

 TaiChiLogo

The place where health dwells

is at the center

of each individual.

 

Longevity and End of Life

The Long Adulthood: Approaching the End-Point of The Process of Living 

 

     "Have you heard of the wonderful one-hoss shay...how it went to pieces all at once...All at once, and nothing first...just as bubbles do when they burst..." Oliver Wendell Holmes

 

End-Point of the Process of Living

     Every process, by its very nature is a continuous unfolding toward an end point. The end-point of the process of living is death. For many, as this end-point approaches, death may not come suddenly or even quickly. Unlike Holmes' wonderful one-hoss shay, some do not "go all at once". Unfortunately, the end often looks more like the "Struldbrugs" of Gulliver's Travels, a people who grew increasingly old, decrepit and debilitated--but could not die!

 

     Because death is inevitable and unpredictable, age-appropriate conversations about death should be integral throughout the process of living--unfortunately, they are not. Our reluctance to discuss death throughout life impacts how we die, and how we experience grief. While the time of death is uncertain for everyone, there is a different profile of certainty at the confluence of circumstance and a very long adulthood.

 

     In our quiet moments, we know that a long adulthood is a time of experiencing the many vicissitudes of aging, unceasingly reminding us of the inevitable culmination: the end of being-alive. Many factors converge to cloud the meaning and significance of death and seriously complicate choices that must be made. This often creates profound heartache for individuals and their families as the natural end of a long adulthood inevitably moves toward becoming-dead.

 

The Process of Becoming-Dead 

    "...the final hour when we cease to exist does not itself bring death; it merely completes the death-process. We reach death at that moment, but we have been a long time on the way..." Seneca, 1st century philosopher

 

     In light of longer life expectancies and the possibilities inherent in modern medicine, the last phase of living--completing the "death-process"--often unfolds as the person progressively shows decreasing vital energy, escalating debility, failing of more body organs and increasing need for medicine to manage chronic diseases. As whole body systems increasingly demonstrate inability to support life, repeating "crisis episodes" ensue, resulting in transporting the person for emergency "treatment".

 

     The immediate crisis is averted as the person is "pulled from the brink" but everyone knows that there will be a next time: these crises are related to progressive, irreversible decline at the ending of life. Predictably, there will be a shorter time interval between "episodes"; this is a process from which one neither "recovers" nor returns to the former baseline. The person drops to a lower level of stability, which is deceptive, since life does go on--albeit with less energy, additional medication, more incapacity and debility--until body systems are again overwhelmed, resulting in another crisis and another emergency visit! This is a frequently recurring pattern that I have come to think about as a very sad "shuttle bus" phenomenon: the significance of the pattern is not engaged and a curious dance of pretense intensifies as the person is "shuttled" to/from emergency rooms. 

 

The Dance of Pretense

     Throughout this process, the person, family and health care personnel tacitly participate in the child game of "let's pretend". One sad unspoken rule of this game is that no one mentions the dreaded four-letter word: dead or the very obvious process unfolding toward that end. This tacit game is often submerged in the illusive quest to "not take away hope", which begs the question: hope-for-what?

 

    And so, it is often in the chaos of yet another "episode"--in the midst of this profound existential reality: the impending passing from this life of a human being--that a do not resuscitate (DNR) order is proposed to the person or family and just as often, is repudiated. The DNR conversation does not take place and predictably, unless nature intervenes, the process of becoming-dead will include more "crisis episodes" in the continuing pretense that "it" is not happening.

 

     Curiously enough, this dance occurs whether or not there is a completed Advance Directive (A. D.), perhaps because the emphasis is on "what you do or do not want at the end of life", generally interpreted in terms of medical or technical interventions. Interestingly, it is not unusual to hear people repeat the mantra "no machines"--but the dance continues. Indeed, while medical/technical interventions are crucial choices to be made, something is sorely missing in the process: perhaps, the missing element is inter-human dialogue

 

The Missing Inter-Human Dialogue

    Whether or not there is an A. D., and yes, hospice, there must be authentic engagement with the person and family, guided by health care professionals to discuss the meaning and significance of the profound event unfolding for everyone--the passing of a life from among us. And yes, they are difficult conversations: we are reminded that (LaRochefoulcald) "neither the sun nor death can be looked at steadily". But we must look! We cannot continue to arrive at the end of a long adulthood woefully unprepared to make choices in an increasingly complex medical system: the choices must be embedded in on-going dialogue.  

 

     In the confusion and chaos surrounding the emergency, the question about DNR is often presented obliquely: some variation of "there is nothing more to be done here". The family embraces the obliqueness, responding that indeed the person should be treated "if they can get better". Sadly,  this is usually where the conversation ends. If "getting better" is explored in open, honest, authentic dialogue--not in the midst of the crisis--the person and family can come to acknowledge that "getting better from an episode" is not the same as "recovering". In fact, the frequency and severity of the "episodes" confirm the progressive inability of the body to sustain life! Authentic dialogue must focus on guiding the family to relinquish the "dance of pretense" as they gradually embrace the idea of impending death.

 

     As the family chooses to engage the process of becoming-dead, they share--together--the pain and sorrow as well as the joy and reciprocal comforts inherent in the memories of their lived connections. And as the literal end approaches.....how can we not engage the opportunity to remember, to laugh , cry and perhaps, apologize for hurts known or unknown...how can we not share fears, concerns, questions...how can we not share the memories of a lifetime in this most meaningful final period? We stand in witness to one of the most profound experiences of living: the passing of a life from this world--how can we continue to pretend that "it" is not happening?

 

In Conclusion

     In confronting the passing of a life--no matter the age--we who stand in witness, must tolerate our own pain as we absorb the awe and mystery of the unfolding process. We focus on deepening the changing connection as we willingly, albeit reluctantly, engage in open, honest dialogue in these final conversations. As the literal end approaches, we reverently embrace the language of silence as the person who is becoming-dead works to surrender the vital energy of living. We may or may not bear witness to the last breath of this life which is the first of the next life--consistent with personal beliefs and faith traditions.

 

Reflections

     As I work with families who have lived the agonizing experience of the "shuttling" phenomenon, I ponder how it is that we have come to this place where death--the only certainty in life--is unimaginable. The answers, as always, are many and varied. Since the beginning of recorded human history, we have sought to conquer death and each era, each generation, each family and each individual addresses this in different ways. And we have seen how the rise of modern medicine has inadvertently mired us in that illusive quest for immortality and has seriously complicated decision-making at end-of-life.

     I reflect on the many different questions, responses and memories that mark the end-point of a very long adulthood: while age must certainly be one of the critical factors to be considered in decision-making,it must never be the only factor.

     And finally, I reflect on the grief that accompanies all loss: the inevitability of death at the end of a long life does not take away the pain of loss. And yet, I hear the unspoken pain of family members who wonder if it is "O. K. to feel sad" when a very old person dies. The grief that accompanies death at the end of a long life must be honored without the clich�s meant to comfort but inadvertently minimize the pain of loss: families need not "apologize" for grieving the death of their very old person: grief is not about age...it is about connection. So, cherish the long connection, grow in the wisdom of all the memories made and when the end comes, grieve your loss, consign the person to the ages and live in the warmth of all that was....as you move forward.

 

Until the next time,

Barbara   

 

            

Join Our Mailing List
Quick Links


A. Barbara Coyne, Ph.D., MSN
The Dwelling Place:Center for Health