Letting Gravity Win

This summer, The New Yorker ran a piece by Atul Gawande called “Letting Go – What should medicine do when it can’t save your life?” I finished reading it on the B train heading into Manhattan, the magazine falling to my lap just as we began to cross the Manhattan Bridge, the two children on the seat behind me screaming in delight at the view down to the water, and out to the buildings, and the moment when it flashes dark as we pass behind the first bridge support, then the second. They pointed to the southbound traffic at a standstill on the FDR and the boats and the birds all passing below us. Then we disappeared into the darkness of the tunnel again, and the children quieted.

Dying is more difficult than ever. It seems we have beaten ourselves at our own game. We created machines and drugs and therapies to make our lives longer and thus better but – in the very end times – the science has taken on a life of its own, and we are left “alive” long past the moment our grandparents would have met their fate. The machines win. I had a checkup the other day and the nurse attached a cuff to my arm, stuck a thermometer in my mouth and pressed a button on a machine that went bing. The cuff inflated, deflated, digital numbers appeared. I read them because she didn’t bother to tell me what they were. She was young, and I wondered whether she had even been taught how to slide a stethoscope under the cuff, how to know when to stop squeezing the rubber bulb in her palm, how to count while listening to the first whoosh and then the quiet as the blood finds its path. Whether she could hold my wrist and, looking at her watch – did she even wear one? – tell me that my heart took its own sweet time between beats. The machine blinked 52 and off we went to the scale.

Gawande’s piece is a confession. It is also reportage, in which he reveals slowly an explanation for the way he acted, not once, but always when faced with patients who were dying. It is his story, but it is shared among many who come bearing bad news in white coats, and, well, all of us humans who are related to other humans we love, who may someday soon face death, as we ourselves will. We are all guilty of having lost the art of dying. He writes:

Dying used to be accompanied by a prescribed set of customs. Guides to ars moriendi, the art of dying, were extraordinarily popular…. Reaffirming one’s faith, repenting one’s sin and letting go of one’s worldly possessions and desires were crucial, and the guides provided families with prayers and questions for the dying in order to put them in the right frame of mind during their final hours.

The customs are gone. The Rubin Museum reminded us by filling glass cases with skulls and human skin this summer, and Killing the Buddha invited us to write. Death keeps appearing to remind us of our mortality.

When I got back from the city a few hours after I finished the Gawande piece, but long before I had shaken its shadow, I watched the Pixar animated film Up. Finally. It was as beautiful as all my friends had told me after they saw it last year. Apparently I was too busy for cartoons at the time, climbing in and out of planes, chasing birds and, almost in passing, I fear, stopping to see my father in a southern Indian hospital. He was unshaven for the first time in nearly thirty years and looked older than his 75. Or, maybe because he has always looked so young, he looked his age. His body of skull and skin had been joined briefly by mutant cells. Brisk men of medical authority opened him up, excised the invaders and other parts of him, and shut him with staples. Tamil nurses sang him back to health.

I stood behind him on that short visit, holding him steady as he shaved, drainage bags dangling on the floor, inadequate gown hanging open. He focused his eyes, willed his hand into obedience. It was time for a new edge, so he slowly slipped the spent blade into its slot, an ancient CVS cartridge that he regularly had me send from the US to India, a brilliant yet defunct design that I can hardly find anymore at the drug stores, crowded out by the flashy new razors with triple action blades and built-in skin softeners. He covered his face with Barbasol. He stroked the blade over the contours, pursing his lips, ran the blade under the slowly running water tap. Mom slept on the cot, deeply, for hours. The Indian silver anklets that she’d taken to wearing on her thin white ankles jingled every now and again with her movement. Meanwhile, 10,000 miles away, my dear friend read his comatose father The Lion, the Witch and the Wardrobe, the book his father had read to him as a boy, before they turned off the machines and let the last of his living body go.

In Up, the main character Carl goes from boy to old man in the first ten minutes of the film. We then watch as Old Man Carl lets go, one by one, of each thing he thought he should hold on to. And each time, there is something better, or at least equally wondrous, waiting for him. There is a good-hearted boy who is in search of a merit badge. And a giant colorful bird that loves chocolate. And a nice dog that loves Carl because that’s what nice dogs do. There are also bad things: mean men and snarling dogs, and moments of pain (although it’s amazing what an old man can do in the virtually muscular and acrobatic world of computer animation), but they have a context within his life story, and they serve as agents of change.

Atul Gawande reminds us that a quarter of all Medicare spending goes to the five per cent who are in their final year of life. He tells us horrifying stories, one after the next. There is a young woman giving birth to her first child and dying soon after, and a 29-year-old man with an inoperable brain tumor, who has a wife, and small children at home who would soon be fatherless. But he also writes about the insurance company Aetna offering hospice care even if patients chose to continue with active treatments. Most companies don’t do this. You are either dying or fighting dying. You can’t, they claim, do both simultaneously. Aetna’s studies showed that you can, and, when given the option, terminally ill patients often chose to forgo the more extreme measures that, statistically, buy them not so much time as the feeling that they’re doing something. As though learning how to face death isn’t enough. The experiment even seemed to indicate that patients benefited merely by having someone to talk to about their upcoming death. He writes:

The explanation strains credibility, but evidence for it has grown in recent years. Two-thirds of terminal-cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Two-thirds enrolled in hospice. These patients suffered less, were physically more capable, and were better able, for a longer period, to interact with others. Moreover, six months after the patients died their family members were much less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish.

There are colored balloons. Hundreds and hundreds of them that lift Old Man Carl’s house right off its foundations and into the sky as he sets off for the fabled Paradise Falls in South America, a belated gift for a beloved wife who is gone. There is a destination, and since everyone has seen the movie but me, I don’t think it’s a spoiler to reveal that once he miraculously arrives there, it’s not what he thought it’d be. He jettisons his belongings, each cherished object but the house itself, and continues on. By the end, the house is gone too, nothing but a shell that contained him for a while until its time was done.

Preparing to die, Gawande writes, comes down to four questions that anyone, at any time in their adult life, should be able to answer.

1) Do you want to be resuscitated if your heart stops?

2) Do you want aggressive treatments such as intubation and mechanical ventilation?

3) Do you want antibiotics?

4) Do you want tube or intravenous feeding if you can’t eat on your own?

Four questions. No wrong answers. But also no “buts” which I find myself, at a healthy forty, wanting to insert. The whole thing requires conversations. Really, really hard conversations. Between doctors and patients, between children and parents, with oneself. But it seems to make the going go better. We should all be so lucky as Scott Nearing, pioneering back-to-the-land New Englander, who decided a month before he turned a hundred that he’d had a good run and would now stop eating, thank you very much. Six weeks later, his life partner Helen wrote in the book Loving and Leaving the Good Life, “he was off and free, like a dry leaf from the tree, floating down and away. ‘All . . . right,’ he breathed, seeming to testify to the all-rightness of everything and was gone. I felt the visible pass into the invisible.” The Jains do the same, following the Acaranga Sutra.

It rarely happens that way, but it could happen more. I’m more Hitchens than hopeful that there’s anything afterwards – reuniting with loved ones seems as fantastical as houses lifted by bouquets of balloons – but most of this country’s 300 million people believe otherwise. Regardless, when the time comes, we should all fight, indeed rage against the dying of the light. Yes. But I hope to prepare too. In the hopes that when the time comes, I’ll know when to cut the balloons to rise up, letting the house fall where it will.

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