Does the VA Nudge Seniors Toward Death?

September 2, 2009 at 3:13 pm (By Amba) (, , , , , )

I didn’t buy the “death panels” rhetoric, but based on this, I’m reconsidering.

Note that neither Hot Air nor the WSJ actually links to the VA booklet.  When you do, the first thing you get is this disclaimer:

Your Life, Your Choices was officially retired from use in VA in 2007, and an expert panel was convened to review and comment on an online module version of this document that was under development at that time.

Ha!  So there are “panels.”  Expert panels.  Doesn’t that make you feel better??  God, I’m so sick of the fucking “experts.”  What does that word cover anyway?  Psychologists?  Economists?  Are there any combat-disabled veterans on the panels?  The only “experts” on this subject are the patients and families who’ve been there, and the good doctors and nurses who’ve been in the trenches with them.

The Your Life, Your Choices online module is currently being revised based on suggestions from the expert panel members and from chaplains representing eight different faith groups.  The revised online module is scheduled to be released on the My HealtheVet Web site in the spring of 2010.

Please note that portions of this document have been interpreted by some to be negative in tone and insufficiently balanced. The revision process is addressing these concerns.  Also note that some of the links contained in the document are no longer active.

Hey, wait, I found the Expert of Experts!  His name is Robert A. Pearlman, he’s the author of the VA booklet, and in this photo at least he bears an uncanny resemblance to Tim Geithner.  (Purely rational Vulcans all?)  He studied ethics at Harvard.  How much more expert does it get?

He received post-residency training as a Robert Wood Johnson Clinical Scholar, a Fellow in the Ethics and the Professions Program at Harvard University, and a Faculty Scholar in the Project on Death in America. He joined the [National] Center [for Ethics in Health Care, apparently part of the VA] in the summer of 2000. His interests and expertise pertain to empirical research in clinical ethics (especially end-of-life care) and organizational ethics. His research has explored euthanasia, the role of quality of life in decision-making, the validity of life-sustaining treatment preferences, medical futility, advance care planning, physician-assisted suicide, and relief of patient suffering. He is the author of two books and over 100 publications in medical journals and book chapters. His most recent book, entitled Your Life, Your Choices, is an interactive workbook to help patients and family members with advance care planning. Your Life, Your Choices will be available to veterans through MyHealtheVet in 2007.

Forget Ezekiel Emmanuel:  is this the government’s Dr. Death?

But now I’m really confused.  The preface to the online booklet now says “Your Life, Your Choices was officially retired from use in VA in 2007.”  Made available and retired in the same year??  Or am I misunderstanding?

Here’s Jim Towey, creator of what he calls “the most widely used living will in America,” “Five Wishes” (not unlike Your Life, Your Choices, “introduced in 1997 and originally distributed with support from a grant by The Robert Wood Johnson Foundation”), being vague about exactly when the workbook was instated (I’m trying to figure out whether the dates need to be jiggered to make Democratic administrations solely to blame for the thing and Republican administrations the blameless heroes who questioned it):

Last year, bureaucrats at the VA’s National Center for Ethics in Health Care advocated a 52-page end-of-life planning document, “Your Life, Your Choices.” It was first published in 1997 and later promoted as the VA’s preferred living will [VA “Fact Sheet” rejoinders that it is “not an advance directive or a living will.”] throughout its vast network of hospitals and nursing homes. After the Bush White House took a look at how this document was treating complex health and moral issues, the VA suspended its use. [VA “Statement” says “The document was developed under a federally funded research grant over a decade ago and in 2007, the Veterans Health Administration convened an outside panel of experts to review the tool and assess its merits. Overwhelmingly, the panel of experts, which included a diverse group from the faith based and medical communities, praised ‘Your Life, Your Choices’ and endorsed its use.”] Unfortunately, under President Obama, the VA has now resuscitated “Your Life, Your Choices.”

Who is the primary author of this workbook? Dr. Robert Pearlman, chief of ethics evaluation for the center, a man who in 1996 advocated for physician-assisted suicide in Vacco v. Quill before the U.S. Supreme Court and is known for his support of health-care rationing.

Here’s a perfectly decent handout on advance directives which, however, refers people to Your Life, Your Choices at the end.

So the booklet was “developed” with federal money during the Clinton years; it’s unclear when the VA began using it; and it’s unclear what happened to it in 2007 and whether its use has now been reinstated without input from “faith panels.”  (The booklet encourages its users to consult religious advisers.)

Looking at the booklet, it certainly hits you right between the eyes with some gruesome though not unrealistic scenarios, and there is certainly a none-too-subtle bias in the discussions against taking heroic measures — or even antibiotics — to prolong a life clearly near its natural end:

Chris Larsen [age unspecified] never told his family what kind of medical measures he’d want if he became critically ill.  He is in a nursing home after having suffered a severe stroke 9 months ago.  He is paralyzed and unable to take care of himself or communicate in any way.  Now he has pneumonia and will probably die unless he goes to the hospital to receive intravenous antibiotics.  He also may need to be  on a breathing machine for a week or so.  The doctor says that his chances of returning to normal are remote, but that he has a fair chance of getting over the pneumonia.  His family members disagree about what they should do. His son Bill says, “Dad was never a quitter.  He’d want to fight to the very end, as long as there was the slightest hope.”  His daughter Trudy disagrees. “Sure, Dad wasn’t a quitter, but he wanted to die naturally—he would be horrified to be kept alive this way.”

In fact, Trudy’s views were the closest to Mr. Larsen’s true opinion. But the family never had a way to find this out. They treated his pneumonia and he lived another year in the nursing home without recovering his ability to communicate or care for himself.

This is on page 5.  It’s offered as an example of why you need to think and talk about these issues while you can.  The trouble with such hypothetical scenarios is that not only do people differ in their values and beliefs, but each case is unique and often unpredictable in its particulars.  After we got to Chapel Hill just about exactly three years ago, J declined both mentally and physically, until in December 2006 he ended up being taken to the hospital with pneumonia.  He certainly would have died if he hadn’t been treated.  His doctors and I agreed that a DNR order (do not resuscitate, i.e. no ventilator or defibrillator) at least was appropriate, and a woman resident asked me if I didn’t think it was time for “placement outside the home.”  However, IV antibiotics was all it took to resurrect J — in a matter of hours, he went from virtually comatose to sitting up in bed talking coherently on the phone to my mother — and it turned out that most of his steep mental decline over the autumn had been due to incipient pneumonia, not accelerating dementia.  The rest is history.  If he were in a late stage of neurological disease, contracted in a fetal position, uncommunicative, and uncomfortable, IV antibiotics would not be appropriate.

(No, he doesn’t have a living will.  Probably the best course for him is to ask him to sign a health care power of attorney.  Though actually, I just learned from this very booklet that if you trust your spouse, that’s who will be consulted in the absence of a POA.  Either way, it will someday be up to me, who knows J best, to decide whether, based on his mental status, responsiveness and awareness, he who loves food so much would want to be kept alive by a feeding tube.  J is also the kind who might well look me in the eye someday and say lucidly, “Let me die.”  But if something happens to me first?)

Naturally, the VA booklet is being quoted selectively by conservative culture warriors.  (The exercise on “What makes your life worth living?” on p. 21, however, doesn’t need selective quoting to be every bit as bad as they say it is.)  Towey in the WSJ notes that “There is a section which provocatively asks, ‘Have you ever heard anyone say, “If I’m a vegetable, pull the plug”?'”  In full, that section merely notes that people sometimes do actually say things like that without being very clear about what they’re talking about:

Have you ever heard anyone say, “If I’m a vegetable, pull the plug”?  What does this mean to you?  What’s a vegetable?  What’s a plug?  Even people who live together can have very different ideas about what the same words mean without knowing it.  When you say, “pull the plug” it could mean a variety of things:
•Stop the breathing machine
•Remove the feeding tube
•Don’t give me antibiotics
•Stop everything

The booklet’s central question is, “For you, is there such a thing as unacceptable quality of life?  Where would you draw the line?”

It’s not that these are bad questions.  It’s, why is the government asking them? (A far more important question than “Did a Democrat or a Republican administration ask them?”)  Or, for that matter, why is an insurance company asking them, or a nursing facility which makes money when patients’ lives are prolonged?  All of these parties have classic conflicts of interest — as, for that matter, can family members eager to be rid of a burden or to collect an inheritance.  Families are not always havens in a heartless world — as Your Life, Your Choices rather ghoulishly acknowledges when it invites you to check “Yes,” “Not Sure,” or “No”:

I believe that my loved ones should take their own interests into consideration, as well as mine, when making health care decisions on my behalf.

I believe that it is acceptable to consider the financial burden of treatment on my loved ones when making health care decisions on my behalf.

The ultimate question is rather like that about sex education:  is this a private matter, even if it inevitably means some kids will be kept in barbaric ignorance or misinformed?  Do you really want some nanny bureaucracy with a “rational” agenda to impose its one-size-fits-all values on the intimate lives of your kids?  Can the transmission of information about such issues ever be value-free?

It’s doctors who should be educated, in the most humane possible way (I mean they should read the humanities, philosophy and literature, as well as psychologists and other “experts”), on these issues, and doctors, together with trusted family members and chosen religious advisers, who should be working out the decisions.  Family doctors used to do this, and no doubt plenty still do.  Yes, it’s a priestly function.  People do look up to their doctors that way in life-and-death situations, so doctors might as well live up to it.

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26 Comments

  1. realpc said,

    Antibiotics are relatively new, and before that people who were weak — because they were very old or very young or very sick — often died. There weren’t as many agonizing decisions,or enormous medical bills. It was normal for parents to lose at least one baby or young child. It was not nearly as common for terminally ill patients to hang on and suffer for years.

    So now we have all these decisions and expenses, and it seems reasonable to communicate about them. Instead of pretending these decisions are normal and can be made easily.

    When our society is in danger or drowning in medical expense I don’t see anything wrong with questioning the value of terminal patients clinging desperately to life. Usually it’s their relatives anyway, and the patients would probably just as soon die naturally.

    I don’t really understand why Catholics, who believe in heaven, became so fixated on earthly life.

    I don’t believe in euthanasia, or making old people feel guilty for living, or anything like that. But limiting futile health care might save a fortune.

    As it is now, medical providers, malpractice lawyers, and health insurers are all taking advantage, and all of them need to be limited and controlled. Hospitals can make a fortune keeping terminal patients alive, lawyers can make a fortune suing doctors and hospitals, and insurers are doing just fine. But the public and the country as a whole are being destroyed.

    So I think increasing consciousness about end of life expenses can’t hurt. Yes it could go too far and become a nightmare, but that’s true of anything.

  2. Charlie (Colorado) said,

    It’s worth looking at the hiustory of that disclaimer, too. the document was retired in 1997, reappeared this year without the disclaimer, grew a milder version of the disclaimer after it was linked by Drudge, and got that version of the disclaimer after the designated fall person was was more or less destroyed by Chris Wallace.

    Personally, I don’t like this doc: honestly, there were times I would have filled it out to say “give me a DNR” several times in the early 90’s when all I really needed was 20 mg of Prozac.

  3. Donna B. said,

    Whenever someone or some group sets about to raise consciousness, it’s done with a goal in mind and it never hurts to question what the goal is and how it’s to be accomplished.

    The first thing that needs to be done is to define exactly what “end of life” means. Is it when a terminal disease is diagnosed? When there are no treatments left that would maintain or increase quality of life? And what does “quality of life” mean?

    But… wait. The above is thing 2. Thing 1 is to ascertain whether our government has the power to define, educate, and/or encourage such discussions. Some will say that since the VA or Medicare is paying for the care that the government has a say. But that say is strictly based on cost.

    Perhaps the gov agencies that pay for medical care should just say there’s no coverage after you reach 80. That’s a few years beyond life expectancy, so that should be plenty, right?

    However aware the entire country might become of the need to address this issue, it still has to be individual/family choices. No regulations can be written that would not be unfairly arbitrary.

    Whatever the choice should be, the government should not be involved in making it or paying others to encourage the decisions as a paid medical service.

  4. PatHMV said,

    The question, realpc, is who decides what is “futile,” and how good are we at determining that? Read this, about concerns being raised in England about seniors being written off as dying, and basically placed under continuous sedation which will mask any signs of whether they are improving or not.

    Even where we know that, say, 95% of people a particular age with a particular condition will die within 2 weeks, we can’t distinguish those 95 from the 5% who will survive with moderate treatment and live several more months or years with good quality of life.

    As I’ve said before, my grandmother was in very bad shape, about 4 or 5 years before she died. She was in a drug-induced coma while doctors tried to figure how and whether she could be saved. Eventually, they (in conjunction with my grandfather, of course) decided to amputate her leg. She perked right back up after that, and had several very good years after that. It’s entirely WRONG, if not downright evil, for the government to insert itself into the decision-making process about whether the care given to my grandmother, while she was in fact close to death, was “futile” or not.

  5. michael grant said,

    I went through all of these questions — some of it fairly hair-raising stuff — when I had my will redrawn in North Carolina. Actually I would have appreciated someone to explain some of the scenarios. Someone other than a lawyer.

    Yes, it’s all rather grim. But it’s something sensible adults should be able to cope with. And it’s a service that the VA should provide. I really don’t see the problem. People die — they should take a minute and think about it, plan for it.

    The alternative is to simply assume that the doctor, hospital, relatives or the government — in the form of law — has a right to keep you in a sort of twilight world of pain near but not quite over the line into death. Personally I’d like to have the right to stop strangers from deciding my end. This is a case where the default setting — keep a person alive and damn the pain, the indignity, the cost to family — is barbaric.

  6. PatHMV said,

    I’ve got no problems with doctors, lawyers, priests, family, and other relevant parties initiating a discussion on the topic. Everybody should do so, because it could happen to you any day. All it takes is one bus and you being in the wrong place at the wrong time.

    But I strongly object to government bureaucrats (which may include doctors, if they are government employees) steering the discussion in any particular direction. And it’s very easy to steer and push a particular viewpoint in such conversations. It takes great care to avoid it, in fact.

  7. amba12 said,

    Charlie: no, wait. The document was created in 1997, not retired. Then “later” — at some indeterminate time between 1997 and 2007 — it began to be used in the VA, given to retirees . Then in 2007 it was either suspended because of concerns the Bush admin had about faith-based perspectives being left out, or it was given an independent evaluation with positive results and submitted to an expert panel, including relgiious ministers. The timeline is very unclear.

    Michael: yes, and sometimes it’s family members who keep you alive and insist that everything possible be done. My uncle was like a Roman — a hedonist and harmless amateur roué when young, a Stoic in old age. One of his sons, raised secular and scientific, converted to Orthodox Judaism. I think it’s against Jewish ethics, but that was the son who couldn’t let his father go and insisted he be put on a ventilator when he’d had a foot amputated (he had atrial fibrillation and so was throwing blood clots), was in agonizing pain, and began to go down with pneumonia. Eventually they weaned him off the ventilator — i think they even put him back on it once and then my cousin finally agreed not to do it again. Then his kidneys failed and they did dialysis a couple of times before they finally let him go. It made altogether for about six weeks of misery for the sake of the living, who lived in Switzerland and California and needed to come and spend some time with their father before releasing him. He couldn’t or wouldn’t speak again after he finally got off the ventilator. He communicated some with his sons, grandchildren and me by raising and lowering his eyebrows.

  8. amba12 said,

    Pat: Notice my story about J. What if someone at the hospital had been pushing me to withhold antibiotics?? The DNR about heroic measures was presented to me as a question, with great tact and delicacy. As it happened, the doctors and I agreed that it was common sense, but I didn’t get the feeling that they were trying to sell me on that outcome. No one pushed me about anything except a little nudge about a nursing home, which I’m impervious to. (Seeing how J deteriorated during two days of uncomprehending generic care just confirmed me in that adamancy. People say, “But what about you?” What about me? What else/better have I got to do? By now I have — subjectively, at least — very little left to lose. What is this glorious full life I should be entitled to have? Cosmetic surgery and trying in vain to pretend I’m 15 or 20 years younger than I am? Ecotourism with Elderhostel? As far as I’m concerned, right now my life is as full as it’s ever going to be again. Could it surprise me? Sure. I could fall in love with somebody’s kid and wind up being an adopted granny-nanny. I could fall in love with some silver fox. I could write a best-selling book on cats. I could end up doing field research on tropical birds or Siberian tigers. But I’m not counting on any of it and it’s all optional. At this age and beyond, I am optional. Or at least, seeing it that way is a good survival strategy right now.) But what if someone had been pushing me, saying “He has dementia, his quality of life is lost, why treat him?” We would have missed the fact that he wasn’t nearly as far gone as he appeared.

  9. amba said,

    In keeping with my Compulsive Copyeditor penchant for eliminating unnecessary syllables from words, I think I’ll just cut to the chase and have cosmic surgery.

  10. PatHMV said,

    Right, Annie. Sounds like you had good doctors, having an entirely proper conversation. But there’s plenty of bad doctors, bad social workers, and bad bureaucrats out there, too. As you undoubtedly know, people faced with such decisions are very vulnerable, emotionally, and generally tired and very stressed. Existing tensions in the family are often magnified. So the family are going to either be in a lock-down mode, where they are fixated on some choice they’ve already made, or they are going to be highly susceptible to any type of persuasion or urging from an individual in authority.

  11. Donna B. said,

    From what you have written about J I consider him to be a “vital” person… one whose presence is full of life, though they may be confined to a wheel chair or bed. I picture him similarly to the way my grandmother was… in a wheel chair and blind but so active in her own way and interested in Life.

    There is no way that one can predict what quality of life they may find acceptable. Had you asked J 20 years ago if he would want to live the way he is living today, what might his answer have been? Is it possible that he might have said… “no way would I want to be confined to a wheel chair!”

    It is not possible for us to define a quality of life that we are not able to accept as long as mental faculties are still working. We are human and we want to live, unless we are suffering from a depressive illness of some type.

  12. amba12 said,

    Donna, that’s true. The human mind and spirit (Geist, dammit) is almost infinitely adaptable. People have devised livable lives for themselves in prison cells. The extreme case must be The Diving Bell and the Butterfly, a book a completely paralyzed man wrote by batting an eye.

    Library Journal wrote:

    [A] marvelous, compelling account of Bauby’s life as a “vegetable,” full of humor and devoid of self-pity. Although he was trapped in the diving bell of his body, Bauby’s imagination “takes flight like a butterfly….You can wander off in space or in time, set out for Tierra del Fuego or for King Midas’s court.” His celebration of life against all odds is highly recommended. [Julia Tavalro, who suffers from the same condition, has also written an excellent account, Look Up for Yes.]

    An Amazon reviewer wrote:

    Public opinion surveys reveal an interesting contrast in modern opinions on the “right to die.” Contrary to the accepted wisdom, the so-called right is favored by those who are young and healthy, but opposed by those who are old and sick. The very premise which underlies such a right is the belief that the quality of life experienced by the aged and the ill is so inadequate that they would willingly choose death instead. In fact, the evidence suggests that–despite the anecdotal horror stories with which all of us are familiar–people generally cling to life even in the face of suffering which seems unendurable to the well. . . . In these times when people tend to complain about the pettiest matters, [Bauby] reminds us that even when life is genuinely difficult, it is still quite beautiful and invaluable and well worth living.

    Because I’m so athletic (not an obsessive exerciser-every-dayer, but someone who could’ve been a depressive deskbound intellectual for whom “getting physical” made life worth living), I can’t imagine being physically incapacitated. Of course it could happen, though. And after a period of anger and depression I would probably adapt and find a quite satisfying way to live. People do it every day, unfortunately and fortunately.

  13. PatHMV said,

    Donna, we wondered the same things while considering whether to authorize the doctors to amputate my grandmother’s leg. She was very politically active, and she danced with a tap dance group of fellow grandmothers and great-grandmothers. She also was very active with animal shelters, helping to take care of the dogs there. We jokingly would say that she will kill us if she wakes up without a leg. But, after it happened, she adapted and made the best of life, and enjoyed most of it.

    Your second paragraph is so right. It’s easy to say “if so-and-so happens, I’d rather just die.” But even people who have said that, and survived to find themselves in such circmustances, very often continue to cling tenaciously to life, and to find joy in their lives.

  14. Charlie (Colorado) said,

    Quickly, because I’ve got conference calls all day…

    * The really interesting timeline is the progress of that disclaimer, the point being that it was originally published with no disclaimer.

    * Serious question, I’m not trying to start a fight: how did you come to the conclusion the “death panels” thing was wrong? Or is it that the phrase itself was too much for you?

    * Something I noticed the first time I was laid up with a bad knee injury is that being impared that way was itself very depressing. I don’t know how to tell the difference between a serious conclusion life isn’t worth living and a depression that could be treated.

  15. amba12 said,

    To answer your serious question: there was no mandatory end-of-life counseling in the bill. If a patient wanted such counseling, Medicare was to pay a doctor for his time thus spent no more than once in five years. There was no requirement that people undergo such counseling or that doctors offer it aggressively.

    This VA booklet, however, reveals how bureaucracies work in practice without the details of their regulations necessarily being spelled out in legislation. Having seen the booklet, I can imagine it being spread beyond the VA throughout the government health system, especially if there was a public option. The “expert panels” that approve, prescribe, or revise it seem to have no accountability to the public (they’re unelected), and there appears to be no public input into the process. It’s bureaucrats choosing “experts.” That smiling Dr. Pearlman strikes me as a creepy character! And it’s NOT that I think the subject of death and dying is taboo. I DO think we need to think more about when and how to let go — of our own lives or of each other. (And of course even then we won’t get it 100% right. That’s impossible.) But I also think (based on experience) that every situation is so unique that there is no way to make a set of rules that will apply to all UNLESS the criterion is the completely impersonal Procrustean bed of cost limits.

    It’s very complicated. I’ve just been reading about current cancer treatments, and how some very expensive, highly touted new cancer drugs (Erbitux?) in fact prolong life by only a matter of weeks. We never get enough of life (unless we’re depressed!), but should the rest of society pay for terminally ill people to extend their dying by a few weeks? On the other hand, the person who wrote that was knocking all those drugs as overhyped, across the board, and mentioned Gleevec, and I happen to know someone who has chronic myelogenous leukemia, which can be kept in remission by Gleevec for many years (and is, in his case), even if it’s almost the only disease that can.

  16. realpc920 said,

    “At this age and beyond, I am optional.”

    You are genuinely selfless. That is good, or not entirely good, just depending on anyone’s point of view. However it’s a bad message for old guys/girls who have been selfish all their lives and now it’s too late for us to change. And when I say I’m selfish I really just mean there are some things I love to do, and I am not different now than when I was a child with crayons. I am selfish exactly the same way as I was then, or in any phase of my life when I became obsessed with trying to learn something. And no matter how obsessed I was with whatever guy I was in love with, the things I loved doing and learning prevented me from being totally relationship-obsessed. These things prevented me from getting depressed in spite of all life’s normal problems.

    These things I have been obsessed with are the center of my life, more important than romantic relationships or family, even though those are very important to me. No one I love intensely has ever died, but that day will come and I don’t know how I will survive it. But I do know that I will still play my banjo.

    And Amba you don’t seem like the women I know whose lives are 100% about relationships and love. You are a creative intellectual, a writer, someone who is interested in many different subjects.

    My advice, which you don’t want to hear, is to work on your selfishness because you won’t always have J to take care of. I am not advising you to be like me, because I am weird, at least for a female (I seem to know a lot of guys with obsessive hobbies and interests, and not as many women).

    But you should find balance, and also please do us oldies a favor and stop saying we are optional after a certain age. I would get so depressed if I ever believed that. I try to pretend age is irrelevant — well actually some things even get better because we have solved some of our worst problems over the years, and we got over our shyness and time-wasting nonsense like that.

    I try to continue loving the things about life I always loved, at whatever age. Of course I think about my age every day and am horrified.

  17. amba12 said,

    Aw heck, I’m selfish that way too. Instead of conversing with J, or keeping him diverted and stimulated, much of the time I’ve got my head in the computer conversing with all of you, or reading something or writing something. In a way I’m just already practicing having a fulfilling life within given limitations. So rather than suggesting that I don’t matter, I should say I’ve found ways to matter enough to stay in the game.

    And no matter how obsessed I was with whatever guy I was in love with, the things I loved doing and learning prevented me from being totally relationship-obsessed.

    Thank God. I can say the same about myself, but just barely, back in the day. Hormones are a bitch.

    Obviously, if I outlive J, which seems likely (I am not pessimistic about that, just aware that no one ever knows), I’m going to figure out how to have a life. It’s more that there’s no point in longing for more freedom just now. It’s better to think I wouldn’t know what to do with it. It’s good not to want more than I have just now, and not to think that I’m entitled to put J in a nursing home because I have such pressing and important things calling to me.

    When it comes to talking about age, we can’t help being propagandized by the culture we live in, which is so horrified by age, especially (but not only) female age, that celebrities would rather erase their individuality (which is what cosmetic surgery does) than proudly declare their vintage. We do need to resist that. I’m different than you in that I would probably feel better about all of it if I had had the child. I really feel I sentenced myself to a kind of obsolescence, irrelevance, exile from the busy center of the world, because 1) you continue to be embroiled in the world through ties to the next generation, and 2) as you get older you see that the ties that really count are the vital ones — especially parents, children, and lovers, then siblings and old friends. These are our visceral priorities. Aunts (even aunties! — an in-joke for a couple of people) are a frill.

    But that’s bullshit too. I’m embroiled with the next generation through this blog, as well as the karate dojo. (I have ties to my nieces and nephews, but dormant and needing to be activated; they’re all elsewhere and busy and I don’t see or communicate with them much. One of them was actually in Chapel Hill and never told me. She was very busy and wouldn’t have had time to come visit us, so she just came and went without a word. That hurt — but she’s promised never to do it again.) And I’m amazed by the responsiveness of little kids to older people, the way they open up and come towards you, all alight, even when you’re a stranger. (According to anthropologist Sarah Blaffer Hrdy, the tie between grandparents, especially grandmothers, and children may have been part of what made us human and enabled us to survive as such, so that affinity may be instinctual, and that would explain why it’s so vital.) I certainly remember older people, and not only my grandparents, being intensely important in my life as a child, and memorable. There were women in their 50s or 60s — teachers, relatives –I had what I can only describe as crushes on.

    You do mourn the drama of being young, when you’re right at the center of life. It’s not just vanity, it’s the excitement and the sense of being in the thick of things. I’m feeling that like everybody else, plus I don’t think I’ll ever get over the abortion.

  18. realpc920 said,

    We have a youth-oriented culture. But our generation still has the massive numbers, so that might change a little. i mean, our generation created most of the youth-obsession, didn’t it? So we could just uncreate it. We aren’t different when we’re old, we just have done more things and had more thoughts. That could be an advantage in some ways, and in traditional cultures it was.

    I am glad you are not revolving around J all the time and that you have a healthy kind of selfishness. It’s so obvious you are not a traditional woman who lives only for her man. Not that I think there is anything wrong with that! What I mean is, complete selflessness would be wrong for a creative thinking person like you.

    As for needing offspring to feel connected to the world, I really don’t know. They do not always grow up to be your pal, and in many cases you would only see them on Thanksgiving, or else on Skype or whatever.

    Since you did not have the child, there is no use in regretting it. But since you obviously have a great love of children you could always adopt a kid that no one wants. So what if it isn’t your own DNA? Wouldn’t it be so much nicer to take in a stray and give a hopeless person a chance at life?

    It’s wonderful that you are doing so much for J, but I am also glad to hear you also spend a lot of time reading and communicating. Do not feel guilty about it! It makes you a better companion for him, because otherwise you would be unhappy.

    The worn cliche says “save yourself first,” and it’s true. A sick depressed person cannot help anyone at all.

  19. amba12 said,

    We aren’t different when we’re old

    We are different. We have less energy, more aches and pains, and less hormones — the latter, a huge difference, and not all for the bad! It’s disorienting but freeing not to be driven by sex.

  20. amba12 said,

    Of course, guys won’t know what I’m talking about. Desire, at least driven desire, (as well as desirability) does track fertility. I don’t mean sex is gone, or that it couldn’t be an expression of love. But it isn’t the rocket tied to one’s tail that it used to be.

  21. realpc920 said,

    “it isn’t the rocket tied to one’s tail that it used to be.”

    Yes that is one thing that is different. It’s exactly the same as ever, if someone else starts it, but you would never think of it otherwise. The mind is freed to obsess over less important things.

  22. Charlie (Colorado) said,

    ““it isn’t the rocket tied to one’s tail that it used to be.”

    That fits my experience, actually. Of course, I’m half woman anyway. (On my mother’s side.)

  23. PatHMV said,

    Rockets in one’s tail? Better be careful, or Titus will be joining us here soon! ;-)

  24. amba12 said,

    The only trouble is that the rocket powered more than just sex.

    Pat: Shhhh!

    I guess the physical drive lets up some for everyone. It may be more in the mind that men stay so interested, maybe because they actually still have a shot at it. There’s something self-protective about not wasting energy wanting what you’re not likely to get (if you’re not happily paired up. Or very rich). Fortunately nature helps.

    Maybe it was Gloria Steinem? who said something like, When my middle-aged girlfriends yowl about the agonies of love, I tell them, So stop taking hormones!

  25. amba12 said,

    Chris the Feldenkrais teacher/PT came to J’s strength training session and she and I did a Feldenkrais Awareness Through Movement “lesson” in the other room. At the end of it my lower back felt like a sixteen-year-old’s and just walking was pleasurable and surprising. I keep forgetting (because I don’t do it enough) how that method banishes the “same old same old” feeling and the “the vital part of life is over” feeling. Not only that, but it’s something you could do and feel renewed even if you were very limited in your ability to move — it’s about quality, mostly quality of attention, not quantity. It’s a fount of endless discovery just of the dimensions of being alive. It’s right up there with the pictures from the Hubble telescope. Taking that training from 2002-2004 really fortified and replenished me during the years when J was slowly getting sicker, even though I then had to drop out when he was falling and could no longer be left alone. But I needed a reminder that going back to that can be just as much of a lifegiver again as it already has been. I could probably also find a way to take a class here once a week, or twice a month, if I made it a priority.

  26. realpc said,

    I don’t know anything about Feldenkrais, but have practiced yoga, or my version of it anyway, all my life. There are all kinds of things like this, and maybe most of them can be helpful. I think one reason we assume pain has to increase with age is that most Americans sit in chairs most of the day. This is unnatural and creates muscle tension and subluxations, and the life energy (qi) gets out of balance. I think we really should pay attention to our spine and muscles, and breathing, and it should be a priority. I had fibromyalgia since I was 30 so I really had to focus on health, which is not what I wanted to focus on back then. I still believed in modern medicine then so I expected MDs to know and fix what was wrong — they told me it was just normal aging! I was 30 for heaven’s sake!

    As a result I learned a lot about chiropractic theory, and I know from direct experience that their theory is pretty much correct. But I think yoga, or similar kinds of exercise, are better than chiropractic adjustments, because no one else can really do it for you.

    Anyway, I imagine Feldenkrais has some resemblance to yoga, chiropractic, Alexander technique, etc., which all involve correcting subluxations and balancing life energy.

    I really think you should make it a very high priority, because I believe mental health starts with physical health. And vice versa, I suppose. But we do need both. If we want to avoid focusing on how we are old and tired and have no energy, we can just do these things that we already know work very well.

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