My mum used to run the Darby and Joan in the village where I grew up. It was a social club for local pensioners. Once a fortnight, she would drive round the village to pick up the members, and take them down to the village hall, where they would drink tea, eat cake, and chat. Most of the members were women who had outlived their husbands. For many of them, it was the only time they left their homes.
Knowing most of the elderly people in the village means that my mum has been to a lot of funerals, and she talks eloquently about the concept of a good funeral. Death is inevitable, but it isn’t always sad. The elderly can reach a point when they are ready to go – they have lived through happiness and sadness, and have passed on to their children and grandchildren whatever they have to pass on. My mum knows this, and I know this: I work as a geriatrician in West Dorset.
As long as death is inevitable, we are invited to either find our peace with it, or suffer the loneliness and anger of having to die. I envy those who find acceptance, and I value the concept of a good death. I have seen it happen many times, and it can be a tender, gentle experience for those involved.
For all its inevitability, death is nonetheless an enforced ending. Given the choice, we might choose to live on, or we might not. But there is hardly ever choice. Death is the end of hope and possibility, as much as it is of life. The meaning of the end is determined by perspective – not just the perspective of the people who are left behind, but the quasi-abstract perspective of the person who has gone. Many of the women my mum knew, and many of my patients, recognise that the moments of note in their lives have passed. They often tell me they have nothing left to look forward to. It’s hard to argue with them.
Each year, they cross the names from their address books of friends and relatives who have died. They watch the numbers dwindle, and eventually one of them is left. They have no one else to ring, to visit, or be visited by. Where else is there for these people to go, except to their graves?
Loneliness is a modern epidemic. By its nature, we don’t see it. Our elders sit indoors, feeling isolated, but not knowing what to do about it. There are many uncomfortable statistics on this theme, but consider that almost 4 million elderly people in the UK say that the TV is their main source of company. Imagine being able to watch the world going on all around you, but without being able to interact with it. Loneliness is a huge risk factor for poor health. It is associated with dementia, suicide, heart disease and death.
And this is where I hit a wall. A lonely old man dies, and we reassure ourselves that that’s alright – he has lived a long life, and had nothing else to live for. But why was his life so empty, and why is it OK that he lived in isolation from family and community? It hasn’t always been like this.
There is a difference between dying as a fully integrated and valued member of a community, and dying outside of society. But we forget this distinction. Being old and frail can predominate the value-judgement we make when someone dies: age and frailty can prevent deeper consideration of the circumstances, as if advanced years and physical infirmity were an explanation, or even a justification, for loneliness.
It is hackneyed to suggest we are just marching towards the end of our lives, because it discounts any intrinsic value to what we might achieve before we die. However, we are in danger of embedding the reality of the cliché in the way we behave as individuals and communities. We fix an unnecessary linearity to the flow of life, from being born into our families, to being ejected out the other side when we are old and frail. There are, of course, contours on the way, but our exit from the embrace of organised society can look as inescapable as our deaths.
Those ladies and gentlemen that my mother helped, those patients of mine who sat at home waiting for the next visit from the carer, were daughters or sons. Most were wives or husbands, and many were mothers or fathers. But now they are members of communities who do not see them, and have no role for them. Or rather, they have ceased to be members of those communities.
Death is the end of hope, but hope can end a long time before it. We live in a world where much of our value is determined by our utility – we either have potential as a child, or we have current worth as a working, economically-active adult. This is a value judgement of our time, and it stems from numerous assumptions. My patients warn me not to get old. Some of this is down to the strain of living with physical infirmity, but it is also founded upon the tacit appreciation that the elderly have neither function nor purpose.
The debate about assisted suicide stems from the tragic cases of younger men and women who have been laid low by progressive or sudden neurological illnesses, but in practice would apply in the majority of cases to the elderly. We label it as freedom of choice, but we will offer it to men and women who are allowed to feel like they have become a burden on society. In Oregon, where assisted suicide is allowed, about two thirds of patients who choose it do so because they feel they have become a burden to their families. In such circumstances, is assisted suicide the free choice of the fully empowered, or is it the corralled choice of people with nowhere else to go?
To be allowed to believe that you are merely a strain on the people around you is to be allowed to forget that you are also a parent, husband, lover or friend. It is a state of belief that narrows the choices that you can make. It flows from the values of modern society, however quietly expressed: a gentle and subtle form of coercion. The language of value today is couched too often in terms of productivity and consumption; indeed, the word value almost seems to have shed its non-financial meaning. We talk about rising care costs, and the epidemic of ageing. This is our frame of reference, and it is our shared fallacy. It is also an accident of our time – the unintended consequence of 20th century changes to the way we live. As we zoom around the world chasing our dreams, following our opportunities, we do not abandon our seniors purposefully. Instead, we launch ourselves into the world off their shoulders, and by the time we realise they need us again, we are miles away, anchored in another place by the responsibilities of our own lives.
The starting point for care of the elderly, and indeed, for the roles of elderly people, used to be the family unit. But as that has disappeared, or at least diminished as an institution, we have replaced it with nothing. So old people drift in and out of our communities, hoping someone well-meaning will take up the slack.
I am often asked about what I am doing as a geriatrician to provide better care for my patients, and there are certainly issues that we need to address. However, the field of my influence extends only so far. The state of care services for the elderly can be seen as reflecting a more general attitude. Two areas of healthcare most in need of improvement are geriatrics and mental health – two patient groups who are unable to advocate well for themselves, and who lack powerful representation. I can help make geriatric services better, but there is more to it that that. Much of what is required needs to happen in society in general and communities in particular.
The poor health that I manage is often directly influenced by the loneliness my patients experience. Fifty percent of my patients have depression, and while I can prescribe the right medication, I cannot give them purpose. That must come from somewhere else.
There is, however, room for optimism. This needn’t be complicated – small changes can make a huge difference. Talk to someone in the grip of advanced dementia about the things they hold most dear, and watch them come alive. Last Christmas, I took my 18-month-old daughter to one of my wards, and for weeks afterwards, patients who couldn’t remember my name were asking after her. Watch also the way that little children interact with the elderly: it is inquisitive and natural. It is also special, because at some point we lose the comfort we have as toddlers and have to relearn it. Watching a child listen to the recollections of a granny or grandpa is a beautiful, symmetrical thing.
It should be easy to spend 10 minutes chatting to someone elderly, or to let them tell your child a story. What makes it difficult is that the elderly exist separately from the lives we lead. There is too little overlap for interaction to be routine. What would it take for the elderly to be reintegrated into normal life? Elderly day centres built next to schools, nurseries to be located in care homes? Tax incentives for the elderly to downsize their homes, and move nearer their families, or into the hearts of their communities? There are lots of options that do not simply involve the health and social care services doing a better job.
It is easier to understand how important it is when you realise what we are currently missing. It is not just that we can judge a society by how we look after our most vulnerable, but something more fundamental: there is a narrative to human history, and the elderly form a significant part of how we make sense of the world. The elderly are our past, just as children are our future: both matter.
I want the elderly to be better looked after because I see their suffering every day. If it is important to nurture our children because of their potential and vulnerability, why not also our elders because of their gifts to us and vulnerability?
You may not think that the world we have inherited from the elderly is much to celebrate, but you should at least acknowledge that you might be wrong about that. In any event, you could always ask them about it.