He fought in a war, jumped out of planes, ran the CIA and the U.S. government, but I bet former President George H.W. Bush would tell you one of the hardest things he has ever done is what he just did: spend seven weeks in the hospital seriously ill. The former American president, who did his second parachute jump as an octogenarian just three years ago, went home from the hospital looking like most of his 88 years had caught up with him in the last 42 days.
On his way home to his family’s loving care, I have to wonder if this thought about the last seven weeks crossed his mind: “There is no way I am going through that again!” He knows the ailments that “earned” him one trip to the intensive-care unit will “earn” him another some day. He knows what this illness and recovery took out of him, literally and figuratively. He knows he will have less chance of surviving a similar illness in the future because serious and prolonged acute illness almost always permanently reduces the physiologic resilience of elderly patients. He knows the next time will be hell.
Knowing all of that, my bet is it not only crossed his mind but stuck there for awhile, perhaps even permanently. He’s a guy who spent his life asking and facing tough questions and calculating odds, and he’s a guy with a lot of guts. A guy like that has almost certainly come to grips with the question: “When should there be no more intensive care, no more emergencies, no more needles and tubes? When should I opt for the comfort of home and hospice, rather than the invasiveness of intensive care?” In other words, “When should I stop trying to live?”
That question is confronting many more of us, primarily because 10,000 Americans are turning 65 every day, and those over age 80 are the fastest growing segment of the American population. Constant illness and increasing disability due to aging slowly deprive us of activities that make life enjoyable. They tag-team us to make life more and more difficult to live, and slowly invite the idea of our death into our lives. At some point life inevitably limits our choices to one of two options: an increasingly arduous, less rewarding fight to continue living, or deciding not to fight any more for longer life.
If we are lucky, we have the mental faculties and time to think about these choices and adjust to them. Over that time, the idea of our death may be accepted, then perhaps a comfort rather than a fear, and a relief rather than solely a regret. Somehow, sometimes, Death the Enemy becomes a kind of friend, or at least an acceptable travel companion.
I have seen patients make this transition many times, and each time have struggled to figure out how they knew when it was time to stop trying to live, and how they came to grips with the knowledge that the time to their deaths was shorter than a good summer, or perhaps even shorter than a good vacation. How did they know when one more day was not worth it, that they would never allow themselves to be put on breathing machines again, or not to be resuscitated if their hearts stopped, or that the last trip to the hospital was indeed their last trip to the hospital?
Physicians and nurses often accept this inevitability for their patients before those patients and their families do, and some of those health care professionals wonder why patients and families take so long to do so. But those who are not going to die soon have the luxury of not having to give up tomorrow, the next Christmas or birthday, the next wondrous summer night, the next hug of a child. It’s easy for them until they have to try it themselves.
Until my turn comes I have no clue how I will know when I should stop trying to live, or whether I will even have the courage to do so. In the meantime, I am honored to have care for those figuring it out.
Erik Steele, a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.