Smoke Gets in Your Eyes and Other Lessons from the Crematory

But this gradual deterioration comes at a terrible cost. There are many ways for a corpse to be disturbing. Decapitated bodies are fairly gruesome, as are those dredged from the water after several days afloat, their green skin sloughing off in strips. But the decubitus ulcer presents a unique psychological horror. The word “decubitus” comes from the Latin decumbere, to lie down. As a rule, bedridden patients have to be moved every few hours, flipped like pancakes to ensure that the weight of their own bodies doesn’t press their bones into the tissue and skin, cutting off blood circulation. Without blood flow, tissue begins decay. The ulcers occur when a patient is left lying in bed for an extended period, as often happens in understaffed nursing homes.

Without some movement, the patient will literally begin to decompose while he or she is still living, eaten alive by their own necrotic tissue. One particular body that came into the preparation room at Westwind I will remember for the rest of my life. She was a ninety-year-old African American woman, brought in from a poorly equipped nursing home, where the patients who weren’t bedridden were kept in cheerless holding pens, staring blankly at the walls. As I turned her over to wash her back, I received the ghastly surprise of a gaping, raw wound the size of a football festering on her lower back. It was akin to the gaping mouth of hell. You can almost gaze through such a wound into our dystopian future.

We do not (and will not) have the resources to properly care for our increasing elderly population, yet we insist on medical intervention to keep them alive. To allow them to die would signal the failure of our supposedly infallible modern medical system.

The surgeon Atul Gawande wrote in a devastating New Yorker article on aging that “there have been dozens of best-selling books on aging but they tend to have titles like ‘Younger Next Year,’ ‘The Fountain of Age,’ ‘Ageless,’ ‘The Sexy Years.’ Still, there are costs to averting our eyes from the realities. For one thing, we put off changes that we need to make as a society. . . . In thirty years, there will be as many people over eighty as there are under five.”

Year after year my seatmate, the gastroenterologist and professor, encountered firsthand a new crop of students terrified of their own mortality. Even though the elderly population continues to soar, he has fought for years to implement more classes in geriatrics (the study of diseases and treatment in the elderly), and is repeatedly denied. Medical students just aren’t choosing geriatric care; the income is too low, the work too brutal. No surprise, medical schools turn out plastic surgeons and radiologists by the boatload.

Gawande, again: “I asked Chad Boult, the geriatrics professor now at Johns Hopkins, what can be done to ensure that there are enough geriatricians for our country’s surging elderly population. ‘Nothing,’ he said. ‘It’s too late.’”

I was impressed that my doctor-seatmate (and bit of a kindred spirit, really) took such an open approach. He said, “I tell dying patients that I can prolong their lives, but I can’t always cure them. If they choose to prolong, it will mean pain and suffering. I don’t ever want to be cruel, but they need to understand the diagnosis.”

“At least your students are learning that from you,” I said, hopeful.

“Well, OK, but here’s the thing: my students don’t ever want to give a terminal diagnosis. I have to ask, ‘Did you fully explain it to them?’”

“Even if someone is dying, they just . . . don’t tell them?” I asked, shocked.

He nodded. “They don’t want to face their own mortality. They’d rather take an anatomy exam for the eighth time than face a dying person. And the doctors, the old guys, guys my age, they’re even worse.”

My grandmother Lucile Caple was eighty-eight when her mind shut down, even though, technically, her body lived on to the age of ninety-two. She had gone to the bathroom in the middle of the night and fell, hitting her head on the coffee table and developing a subdural hematoma—medical-speak for bleeding around the brain. After a few months in a rehabilitation center, sharing a room with a woman named Edeltraut Chang (whom I mention only because hers was the greatest name ever assembled), my grandmother came home. But she was never the same, transformed by her brain damage into something of a loony tune—if I may throw around another fancy medical term.

Without medical intervention, Tutu (the Hawaiian word for grandmother) would have died shortly after her traumatic brain injury. But she didn’t. Before her mind was blunted, she had insisted, “For heaven’s sake, don’t let me ever get like that,” yet there she was, stuck in that depressing place between life and death.

After the subdural hematoma, Tutu would tell long, fantastical stories to explain how she had fallen and hurt herself. My favorite was that the city of Honolulu had commissioned her to paint a mural at the entrance to City Hall. While leading her merry team of painters on an artistic quest up a mangrove tree, a branch had broken and she plummeted to the ground below.