Way in the back when I worked in a Retirement Center. It was the ambulatory wing of a nursing home where there was still carpet in the common room and people had their furniture and personal belongings around them if they liked.
I worked four shifts a week on Saturday and Sunday: 7 a.m. to 11 p.m. I helped serve breakfast, lunch and dinner and handed out pills twice or more a day in little white paper cups that had been filled for me by the RN on staff.
After dinner I would wash sheets and towels in the large industrial washing machines. And once I took one of the residents to the doctor's in my mother's car. I don't remember why I offered or was asked. I just remember what happened. While I was gone, one of my people died.
I thought of them that way, as my people. They were two dozen odd grandparents of choice. Two with Alzheimer’s, two married couples. One new admit who was so tiny and well loved she looked like a dried apple doll next to her strapping son. A table full of diabetics who could only have one piece of white bread at lunch.
"Take care of Mama," he said to me. I remember his voice had a honey hint of the south. "She doesn't eat enough to keep a bird alive." And he held his hands out to make a small cup of them to show me how little she consumed in a day.
Mama, George and his wife, Millie and Betsy, Mr. and Mrs. Johnson. I suppose they are all long gone now. Millie with her jelly jar she brought out one evening to give me, full to the brim with prescription medications she wasn't bothering to take any more. "They don't do me a wit of good," she said, and her hands were warm and soft when she held mine.
George had a problem with incontinence which everyone, even the staff was trying to hide. Only people who were ambulatory, continent and could feed themselves were allowed "upstairs." Upstairs with the carpet, and the college student who would listen to their stories while she folded laundry until the theology student arrived for the overnight shift. Or perhaps they would watch the Love Boat because that was what was on.
George and his wife lived in a room that smelled faintly of urine. He didn't move quickly, but he and his wife walked up and down the halls for exercise most of the day. I didn't know at the time that shambling gate and unfocused gaze were the stigmata of dementia. Downstairs was a scary place where LPNs left their elderly charges posied into wheel chairs lining the hallways during the day, some scrabbling faintly with their feet to move a few feet.
A man whose name I never knew lay in bed naked and masturbating most of the shifts that I picked up during the week. I wore white scrubs when I worked on that floor.
But that isn't what I wanted to say. I wanted to tell you about the Mild Cardiac Infarction. That's what I heard the nurse say when I got back with my pillow plump charge from our two hour excursion to the hospital. We had been so worried about George, we had never thought of the Johnsons who had the nicest double with lovely matching blue bed clothes, drapes and carpet with a view onto the center courtyard.
It never occurred to us to worry about Mr. Johnson. I didn't understand how a mild heart attack could kill you. Somehow I felt it was my fault. After all I'd been trained in CPR when I was a 14 year old girl scout. I felt even worse to be glad to have been away when he'd keeled over at the lunch table. Mr. Johnson sat at the back table in the right corner. He took the side with the windows to his back so his wife could enjoy the view.
Mrs. Johnson had to give up her plush double and move downstairs where the squeak of white nursing shoes was never absent and the nurse's aides would sneak out to smoke between helping someone with a sponge bath or feeding someone else.
My mother was an RN who sometimes worked the floor and sometimes taught. She would rail about the little old people who were sent from the nursing homes to be rehydrated and pumped full of antibiotics or put on feeding tubes.
"No one wants them to die," she said. "So they pump them full of fluids and everyone hopes they die in the ambulance on the way back so it doesn't go on anyone's stats."
I never learned to take a blood pressure. I was only really good at listening to stories and handing out paper cups full of pills, and to this day I can fold sheets by myself into tight neat packages.
I know that what you measure is what you get, and even though we are all going to die, that nursing home didn't want anyone to die on their watch. When they get incontinent send them downstairs. When they stop eating send them to St. John. Five percent of all Medicare recipients die each year. They account for thirty percent of Medicare dollars.
According to Medicare Beneficiaries Costs of Care in the Last Year of Life
...for beneficiaries not in a nursing home, not in a managed care plan, and not dying of cancer, the health care system offers little support for end-of-life care other than through traditional acute care providers. Surveys suggest that about half of persons with a serious chronic illness would prefer to die at home. Hospice provides organized support for in-home death, but hospice remains typical only for those dying of cancer.
End of life costs are high. These are frail elderly people with an average of four serious diseases...that no one wants to count against them on their statistics, so absent direction otherwise, ambulances are called, feeding tubes inserted and little German immigrant ladies whose English is fading and who aren't even eating as much as would fit in the small cup of your hands aren't allowed a peaceful exit once they've given up their own homes and been welcomed Upstairs.
But how can you have this important conversation with all the noise going on? How can you be grateful for the Myocardiac Infarction that so traumatized your younger self, knowing it left Mrs. Johnson alone in a single bed in a double room off the hall lined with wheel chairs. Knowing she was left to less tender mercies.
How can you stand being in a room with people who insist Obama's going to kill Granny, when you know in your heart that Granny knows when she's finished her work here, and the tremulous clenching and unclenching of the blanket in her lap are the last few stitches of the quilt she's finishing in her mind’s eye? How can you have it knowing your own ambivalence and early ignorance? How can you know?