Maud is eighty-six years old, and weighs just that many pounds. She is nearly bald; her thin, fine, white-gray hair has been rubbed nearly away by all her years in bed. At her age she is balding around her genitals as well, worn and loose where the catheter tube emerges. She is bare like a young girl, but the work of decades has left its erosion.
Maud had a stroke years ago, and then another and another. She doesn’t open her eyes, never speaks. She is fed with a big plastic syringe that the nurses slip past her resisting lips; the right amount of pureed chicken or spinach tickles the back of her tongue and makes her swallow, involuntarily.
Tonight I discover that Maud has cellulitis, an odd but common infection under the skin. Her right hip and buttock are red, swollen, hot; she has a temperature of 104 degrees. I call her doctor. He asks me, “If you were her granddaughter, would you want me to treat her?” “I’m not her granddaughter,” I answer. “You know,” he sighs, alone in his office, wanting to go home, “I promised that lady years ago that I wouldn’t keep her alive like this.” He pauses, and I wait. “I promised her.” Eventually he orders an antibiotic, because of the slight chance Maud’s infection could spread to another patient, and her temperature drops in the evening, and she goes on.
I am often asked how I can stand my work, and I know that it is this very going on that my questioners mean. Not only the uninitiated, but other nurses and physicians often dislike this “gutter work” that I do: part-time charge nurse in an old, not very good, urban nursing home, working with the sickest patients, the ones who won’t recover from an unfortunate age. Some of the nurses I work with are always looking for a “better” job, competing with thousands of other nurses for the hospital positions grown suddenly scarce in recent years — hospital jobs where patients come and go, quickly, and sometimes get well.
I feel a measure of peace here, a sense of belonging, that is rare for me anywhere else. Partly it is because I know what to do, because I am competent here. Over the years, though, the ease that I’ve felt since my first job as a nurse’s aide when I was eighteen has become layered with fondness, the way one grows used to a house and its little quirks, the slightly warped kitchen floor, the sighing upstairs window. Here all is aslant, and I have to tilt my head a bit to see it clearly.
Coming in to begin a shift, I pass the activity room, crowded with hump-backed, white-haired people asleep in wheelchairs, facing a man playing the “Star-Spangled Banner” on a musical saw. In the corner, one upright, perfectly bald man spins slowly round and round in his chair, like a wind-up doll, bumping the wall at last and spinning back the other way. This is a scene of astonishing absurdity, and no one is paying any attention to it. We take it for granted, like the faint, lingering smell of urine tinged with kitchen steam and disinfectant. I leave the elevator on the third floor and step into furnace heat — July without air conditioning — and the queer conversation of the confused that will dog my steps all evening long. They give me this gift of skewed perspective like a gift of non-Euclidean sight, so that I become as willing to dip and bend with the motion of a damaged cortex as a tree in wind. I pass medicine room to room, and in each room the televisions are tuned to the same channel. For my 4:00 pass, it is “People’s Court,” plaintiff and defendant, as I travel down the hall. At 6:00 we watch “Jeopardy.” “What is the only military medal that can be given to noncombatants?” asks the host, in Monte’s room; then I pass next door to Sylvia, and together we guess: “The Medal of Honor.” And we are right. Bent over a task, preoccupied, I am startled by the peculiar speech of the nerve-worn, its sudden clarity. Up here each day is the same, a refrain, and nothing can be taken for granted, nothing.
I know how many people hate nursing homes — hate the word, the notion, the possibility. A friend of mine lives next door to a local nursing home, and she tells me she hears people screaming in the evening, unseen, their voices leaping the tall fence between. She assumes the worst, my friend: that they scream from neglect, from abuse, from terror. She says it is a “terrible place,” never having been inside. I tell her that in every nursing home, there are people who scream; that they scream without warning, at private phantoms. I ask her where such people should go, I ask her how she would stop them from screaming. She listens and I know she is unconvinced. Nursing homes are terrible places, she says, and it is because what happens there is terrible.
(I am similarly fearful around big machinery, in boiler rooms and factories. I am out of place, adrift, and fear the worst: is that shower of sparks routine, or does it signal disaster? What is that loud noise.)
I enjoy my work, but I enjoy it in moments that are separated from each other by long stretches of fatigue and concentration. I enjoy it best when it’s over. I catch myself, hot and worn at the end of the day, hoping the man I keep expecting to die will live until the next shift. I get irritable, and the clock creeps past 11:30, past midnight, and I’m still sitting with my feet propped up, trying to decipher my scribbled notes. The undone tasks, the unexplained events that want explaining, badger and chafe. And everybody dies.
My ideals twitch on occasion, like a dog’s leg in dream. I want no one to lie in urine a moment, I want every ice pitcher filled at every moment. For a long while, for many years, I disliked the use of sedatives and antipsychotics to knock out the wound-up chatter of restless, disoriented souls. The orders read: “p.r.n. agitation” — as necessary — and this is the nurse’s power to ignore, and the power to mute. So easy to misuse, so simple. But like a shot of morphine can break the spiraling cycle of pain, so can a spiral of panic be broken — not for my comfort, but for the comfort of the panicked.
Sadie screams at me from far down the hall: “Help! It’s an emergency!” And she screams over and over, rocking back and forth, till I come to see; she leans over and points at the blazing fire under her bed, a fire she sees and hears and smells, raging out of control. I see no fire. I coo to her, hushing; she babbles on. Finally I lie beside her on her bed; she is stiff and yearns to leap up. And, at last, I go to prepare the syringe: “From the doctor,” I tell her, because Sadie loves her medicine, and she falls asleep.
The responsibility is mine, the consequences are mine. I have to be sure about choices no one can be sure about. I call for nurse’s aides to come and hold the flailing arms and legs of Charlie, more than six feet tall, furious at the world that confounds him so. He squirms and tries to bite me when I hit his hip with the needle. We all fall across the bed together, grunting. And I know that the visitor, passing by, sees only the force, the convenience, the terrible thing we have done to this person: the abduction.
The same is true of the smell, just barely there, acrid in the heat. It’s true of the drooling, the patter of nonsense in the dining room. Visitors tremble, knowing Grandma is here, and wish they had the courage to bring her home, out of this awful place.
Could this inadvertent audience, my patients’ families, see these scenes and believe me when I say it is a labor of love? Some do; they bake blueberry pastries and doughnuts for the nurses, pat us on the arm, cluck their tongues. “I don’t know how you can stand it,” the niece says, after an afternoon at Aunt Louise’s bedside.
The difference here is in what we call love, the gap of definition between their words and mine. Their burden — and they seem to really want to know — is a burden of despair, a personal burden, bred of fear and impotence in equal amounts. This personal despair imagines as its opposite, its anima, a personal love and a personal sorrow. The visitor sees May defecating helplessly on the rug before anyone can stop her, and it strikes his identity, his self. It is as though the observer himself stood there, revealed. I have the advantage of knowing May will forget it in an hour; he does not. In breathless confession, waiting for the elevator, the visitor says: “I pray to God I die before this happens to me.” I am told this again and again. “I pray to God.” A kind of ego-terror is born, and with unbordered empathy comes flight. Suddenly the sounds and smells oppress, overwhelm. Suddenly it’s time, more than time, to go.
A labor of love, love for fading people who dwell in shadows. I am saved from the need for flight — I am uninjured — because I let them do their own suffering. This is a cold-sounding excuse, I know. Call it compassion instead of love. (I am surprised, and pleased, just now, to find that Roget’s Thesaurus lists as a synonym for compassion and kindness the less lofty “disinterestedness.” I have learned not to make personal what I see; not, as it were, to anthropomorphize my patients’ experiences. Just as the witness imagines himself, complete, transformed to this place and trapped, so does he grant full imagination to those who are. He assumes Maud is aware of her plight, ruminates on her fate. I grant Maud plenty, without granting full cognizance in her withered brain. Down the hall from Maud is a man in his forties, paralyzed from polio, limited to a respirator, and he is fully cognizant: no pity for him, either. Pity makes distance, creates a separation of witness and participant; by assuming a person is absorbed in suffering, the witness prohibits them from participation in anything else.
I close the curtains, keep my voice down, as a point of etiquette as much as sympathy. I have a spring in my step; I can see and hear; I can eat and digest and control my urine, and I know these for the blessings they are. I am young enough, still, to take care of the old. But these are the most transient of graces, these graces of health, and I might lose them all tomorrow if the brakes fail. Old and sick comes later — but it comes.
Here everybody dies. We tell black jokes. (I laugh and laugh at a cartoon of an old man sitting up in bed, surrounded by impatient doctors: “These are my last words,” the old man says. “No, these are my last words. No, no, wait. . . .”) We have a three-part mythos of death here, and first is that no one dies when we think they will, always later. Second, if a person long ill and silent suddenly comes to life, he or she will die soon. And last, people die in threes. Within a day or week of one death will follow two more. Just last week, Monte died, days after we’d predicted, and now Mr. H. down the hall is talking again, after months of sleep.
Death is anticipated, waited on in suspense. It is like waiting in a very long line that snakes around a corner so you can’t see the end. When the last breath is drawn it is startling; here is a breath, and another, and another. Death is the breath after the last one. Always fresh, always solemn, and not unlike a childbirth: the living let their own held breaths go, and smile, and in the solemnity is an affirmation. Here it is. I stroke the skin so suddenly and mysteriously waxen. I pull out tubes and patch holes. I like dead bodies: at no other time am I so aware of my own animation. This isn’t because I am lucky and this poor fool is not, but because here before me is the mute, incontrovertible evidence. Some force drives these shells, and it drives me still. I am a witness, an attestant, to a foresworn truth.
Here it is. I stroke the skin so suddenly and mysteriously waxen. I pull out tubes and patch holes. I like dead bodies: at no other time am I so aware of my own animation. This isn’t because I am lucky and this poor fool is not, but because here before me is the mute, incontrovertible evidence. Some force drives these shells, and it drives me still.
Still I have my own despair. For me it is the things undone that break my back sometimes, the harried rush with people calling, and all those unexplained events. I wish we could ferret out the meaning in all this chaos, talk it out. No time — sometimes the ice pitchers are dry all night. Last week I had a shift like this, split in the middle by an impatient doctor who snapped his fingers at me and tapped his toe in frustration at my slowness. An hour later another doctor dropped by, and I asked her to see a new patient, with a minor but uncomfortable problem. She refused, and then explained. “Medicine is the kind of job where you have to be really careful not to let people take advantage of you,” she said. “Somebody always wants something.” And all I could do was look at her, and get back to work.
I have to remember to temper my criticism of the aides, who work at least as hard as I do in a job of numbing repetition and labor. Hardest to remember when so much is left unfinished is what I have managed to do. I think I’ve been of no help at all, and then realize how little help I’d be if I got discouraged and quit. Every task, no matter how late, every kind word, no matter how brief, makes a difference.
In my first job as an aide I cared for a Swedish woman named Florence, who had only one leg. She was happy and confused, and didn’t know she’d lost her limb. Time and again she would try to walk, and fall. I tied her in her chair, in her bed, and over and over she managed to untie herself and fall, thud, to the hard tile floor. She was always surprised. Exasperated at last, I stood over her and asked, “What am I going to do with you?” And she looked up from where she sprawled and said, “Don’t stop trying, dear.”
Don’t stop trying. This is far from the best nursing home. It isn’t the worst. I rant, jump to complain, go home frustrated. It should be better. But the sheets are changed, people are fed, for the most part each one is treated with kindness — a clumsy, patronizing kindness at times, but many of them don’t discriminate these fine points. Kindness is enough. Thousands, hundreds of thousands of people, have joined these ranks, saved. There is no place to go but on, and on.
I like dead people and all their apprenticed fellows like Maud, who, slowly, is learning to die. And I like this place, with its cockeyed, terpsichorean logic. I will feed Maud her squirts of puree and a few minutes later Sadie will announce she is the Queen of Germany, and requires royal treatment. Celia will cough up blood, and, as I consider my options, I will hear distant bedrails shake, the curses, the rhythmic, pattering singsong. Sometimes the borders shift even further. I sprawl across a bed, fiddling with Roberta’s leaking catheter, trying to disentangle her fingers from hair. The tube feeding drips on my leg. Who is keeper, who is kept? This is the Marx Brothers all grown up, slapstick matured, life imitating art imitating life. Down the hall the Greek Chorus begins, explaining the meaning and the mystery as the melodramatic story limps along.