Maintaining the Integrity of One's Life

Aug 13, 2018

There is a growing new culture in long-term care. The Green House project, founded by geriatrician Dr. Bill Thomas, features a large, centrally located kitchen and dining room designed to be the heart of the home. Residents often take part in meal planning and preparation.

In his book Being Mortal, Dr. Atul Gawande discusses nursing homes and why 50% of us will spend a year or more of our lives in one. The other 50%, especially if we are in the very old category, will live alone. Unfortunately, Gawande observes,  “We give virtually no thought to how we will live out our later years alone.”

A recurrent theme in his book is that our failure to confront, to think about, or to plan for our later years makes them worse. Why does this happen? Gawande argues that we feel aging is unpleasant so we don’t think about it; then, we aren’t prepared. Lack of preparation makes the problems of aging worse. He argues that things could be better.

For example, we know that the risk of falls increases with aging. The risk of falling is higher if the person has poor balance, is taking more than four medications, and has muscle weakness. Acknowledging that risk could allow us to put support bars in our showers, be sure we have good feet with nails trimmed, appropriate footwear, and no throw rugs to trip on.

Because as Gawande points out, “Old age is a continuous series of losses” and because we deteriorate without plans for the frailty that comes with old age, we end up having to “choose between neglect and institutionalization.” Unless we are wealthy or have a child, usually a daughter, to care for us, we enter these warehouses for the decrepit, frail elderly where we lose “all privacy and control.”  

Gawande discovers that it doesn’t have to be this way. He finds Dr. Bill Thomas who graduated from Harvard Medical School and first worked as an emergency room doctor, but then took a job as medical director of a nursing home. What he found was depressing, rules oriented, regulated institutional living. Thomas saw that such an atmosphere makes life not worth living. So he convinced the administration to make changes to confront “the Three Plagues of nursing home existence: boredom, loneliness, and helplessness.”

He pushed the envelope with the health department regulations, but was able virtually overnight to bring in green plants, cats, dogs, and one hundred parakeets. There was considerable opposition and resistance to these additions. However, after two years, compared to a neighboring nursing home, Thomas’s had 50% less drug use and a 62% saving in drug costs. Deaths fell by 15%.

Not all nursing homes have improved, but some in Amarillo have cats and birds, much beloved by the residents. Thomas noted a change in his nursing home: “People who we had believed weren’t able to speak started speaking. People who had been completely withdrawn and nonambulatory started coming to the nurses’ station and saying, ‘I’ll take the dog for a walk.’” 

Gawande argues that this improvement in nursing home residents occurred because “we all seek a cause beyond ourselves” - a principal expounded by the philosopher Josiah Royce in his book, The Philosophy of Loyalty. Royce argues that “We all require devotion to something more than ourselves for our lives to be endurable.” Caring for cats, dogs, birds, and plants give us one reason to live. And this is what is new and important, Gawande argues, something simple that makes life meaningful in old age.

“The battle of being mortal is the battle to maintain the integrity of one’s life.  The professionals and institutions we turn to should not make it worse. …their job is not to confine people’s choices, in the name of safety , but to expand them, in the name of living a worthwhile life.”

This will require a change in goal from one of safety and security to one that looks toward not sacrificing “autonomy just because you need help in your life.”