Overliving

The patient’s apartment is full of books. I am there on a home visit during the last year of my medical residency. A whole shelf is devoted to Virginia Woolf. I ask which novel she likes the best, and am surprised when she says The Waves, a lyrical book of sensation and consciousness, with hardly a narrative at all. Out of the living room window you can see Lincoln Center. This, I think, is the way to live at ninety-five.

She tells me she wants to die. The reason is that she can see how things are likely to go. She will fall one morning and paramedics will be summoned to pick her up. Caregivers will be invited into her home. The pain in her knees and back will worsen. Disability is coming, it cannot be avoided, she says, and it would be better if her life were now simply to cease.

Months later, in a nursing home, a second woman, nearly 100, with a sister upstairs who has just turned 103. A nephew visits with his wife once or twice a week, but never a great-nephew, who accepted her gift of a lightly used Oldsmobile when she could no longer drive it but has come only a handful of times in all the years she has been there. More and more she finds herself out of breath with critical aortic stenosis. She understands there will come a time when she can no longer walk or even talk on the phone, and hopes for the end to come swiftly.

I struggle to find a name for this state of thinking. Is it depression? Is it a chronic adjustment disorder, with very old age being the stressor that causes an obstinate low mood? A psychiatrist friend tells me about Erik Erikson and wonders whether the word I am looking for is despair. I go to the library and read about the life cycle, Erikson’s account of human development as a series of crises in which struggles between antitheses allow our basic strengths to emerge. In the eighth and final stage of life, despair is set against integrity, which is the sense of coherence that comes when you have finally figured out how the puzzle pieces of your life fit together. Out of the conflict can come wisdom or its opposite, disdain. You may discover “an informed and detached concern with life itself in the face of death itself,” or instead react “to feeling (and seeing others) in an increasing stage of being finished, confused, helpless.”¹

I decide to speak a senior geriatrician in my department. She tells me she sees elderly patients like mine all the time. What word does she use for these men and women, I ask? They are “just done,” she says.

At one visit to the nursing home, I find that my patient there has been losing weight. I suggest a drug called mirtazapine. I tell her I have seen it improve mood and appetite and sleep. I can see that the subject makes her weary. It is evident that she has had this conversation many times already. She tugs at the oxygen tubing beneath her nose and tells me she is not eating because she is too winded. Do I have any ideas about how to fix that?

Before I decided to become a doctor, I was a graduate student in English literature, and spent years reading and thinking about John Milton. I find myself remembering a pivotal scene in Paradise Lost. Adam, who has eaten the fruit forbidden by God and knows this means he must die, wonders why he is still breathing. “Why do I overlive,” he asks, “why am I mocked with death, and lengthened out / To deathless pain?” Adam is horrified at living past the time when he feels he ought to have died. This overliving comes with no explanation, and it seems to him indecent and possibly cruel. (Compare the effect of “Why do I overlive?” to the usually positive connotation of “survive,” which has the same root meaning.²)

Adam’s verb, overlive, stays in my mind over the next few months. It helps me understand what happens to my patient in the nursing home, to make sense of the mixture of bitterness and resignation as she becomes confined to her wheelchair and does not even try to speak to me when I see her. She enters hospice care and dies shortly after turning 100. Later, I try to track down the other patient, the one near Lincoln Center. I can longer find her. I still think of her often, and like to imagine her in a chair rereading The Waves. She nears the end – “let me sit here for ever with bare things, this coffee-cup, this knife, this fork, things in themselves, myself being myself” – and I hope she has found peace.