Portal de Periódicos da CAPES

Impermanence and Loss

2019; Elsevier BV; Volume: 20; Issue: 7 Linguagem: Inglês

10.1016/j.carage.2019.08.015

2377-066X

Karl Steinberg,

Theology and Philosophy of Evil

Although it is a beautiful time of the year, autumn is a season where impermanence is especially apparent and losses abound. Yes, another summer has come and gone, and it has flown by so quickly! Now well into my seventh decade of life, I am no longer shocked at how fleeting each season of each year seems, but I’m still a little saddened and frightened by the apparent headlong acceleration of life’s trajectory. Not so much because of the mystery of the finish line, but more because of the inevitable losses that predictably come with aging — and that I have the privilege of observing and caring for in others through my work every day. Don’t get me wrong, I plan to stay healthy and independent as long as I can. I take fairly good care of myself, ran a half-marathon in under 2 hours this summer, and I halfheartedly hope that when my number is up, I have “the big one” in my sleep with no warning and no chronic illness or disability preceding it. Although I do see the benefits in knowing the end is not far away, with opportunities to say meaningful goodbyes, to explicitly tell loved ones I love them, make amends, forgive — to do Ira Byock’s “four things that matter most,” and take care of other important unfinished business. My preference is irrelevant anyway because usually we don’t get to pick, and I will accept whatever kind of last chapter comes my way as serenely as I can. Yes, I am invoking the Serenity Prayer, but I can’t help myself: accept the things I cannot change, change the things I can, and recognize the difference between them. Acceptance is a great, life-changing virtue, and acceptance of the impermanence of just about everything is worth striving for, although difficult. I remember hearing the Kansas song “Dust in the Wind” as a high school kid, and I really didn’t like the concept. I was most certainly not “just a drop of water in a raging sea.” And “All we do … crumbles to the ground though we refuse to see” did not fit into my worldview at all! Today it’s much easier to accept how infinitesimal and fleeting my life is. It’s not unimportant or meaningless, but it is certainly a tiny speck in the scale of the universe. Working with the hospice/palliative and post-acute/long-term care patient population keeps me very aware of the impermanence of many things, which makes me all the more grateful on a daily basis for the people, pets, attributes, abilities, memories, and other things I have not lost. But I can’t help ruminating occasionally about all that has come and gone in my life. My mom, my grandparents, many beloved pets. The beautiful house in Cleveland Heights I thought our family would have forever. A whole trunk of memorabilia, photos, and my Harvard diploma. My medical school textbooks and handwritten notes. (That last bit, I was convinced to throw away in the interest of downsizing and making a move between homes more efficient. I thought it might be cathartic, and I couldn’t argue with the “you’ll probably never look at them again” logic. But it wasn’t cathartic, and I actually am still sad that they are gone 10 years later. Yes, I probably have some hoarder genes and probably need some therapy.)In working with our patients, I’ve learned that people can live, and live well, even after losing things they thought they could never live without. And barring some medical miracle, I’ll never run 100 yards in 10.6 seconds again or swim 50 yards in 22.9 seconds; I’ll never do 35 hands-forward chin-ups, hold my breath for almost 3 minutes, or recite the Gettysburg address, the periodic table (it seems much longer now than it used to be), or the Krebs cycle. I’ll never again play the guitar solos in the Allman Brothers’ “Blue Sky” accurately. I’m fine with that, and when I look at that list, it’s a little embarrassing to think that these trivial deeds were meaningful or important accomplishments in the first place. But I’m human, and I admit that they provided me some pleasure and a sense of achievement, for whatever they are worth. In working with our patients, I’ve learned that people can live, and live well, even after losing things — spouses, abilities, tangible items — they thought they could never live without. This is a valuable lesson. Caring for a young quadriplegic patient injured in a diving accident or a surgeon who has gone blind from macular degeneration helps keep my own losses in perspective — and I am in awe of the grace and courage with which my patients navigate, process, accept, and move past their losses. Humans are remarkable beasts, our speck-of-dust status notwithstanding. One physician writer, Dr. Sunita Puri, has written eloquently about impermanence and how it relates to our work as healers and companions to our patients as they endure illness and dying. Her short essay in the New York Times (Mar. 7, 2019; https://nyti.ms/2ZqPQ38) will give readers a taste of Sunita’s wisdom and perspective, and her book That Good Night (Viking, 2019) is highly recommended for those of us who may struggle sometimes with our own emotional attachments and compassion fatigue in caring for the seriously ill. As she says, coming to terms with, and ultimately embracing, our own mortality can be of immense value for those of us who do this work: “For we will each age and die … We will lose the people we love. No matter our ethnicity, place of residence, income, religion, or skin color, our human lives are united by brevity and finitude, and the certainty of loss. Just as we strive for dignity and purpose throughout our lives, well before the light fades, we can bring this same dignity and purpose to our deaths, as we each journey into our own good night.” Although I readily accept that my days are numbered, I fear that I personally have a long way to go to reach that point of actually embracing my own mortality, but I plan to work on it. And a deep understanding of the impermanence of our physical existence definitely already helps me be present and invested in traveling the road of serious illness, dying and death together with the patients I have the privilege to encounter. I’m not looking forward to my predictable (and unpredictable) future losses, but I plan to accept them as they come, once I have changed the things I can! And these days, when I go see Kansas (like many ’70s bands, they are still touring, with varying percentages of the original lineup) and hear “all we are is dust in the wind,” it definitely resonates a lot more. Then I’ll blink and another autumn will be upon us. And then it won’t. Dr. Steinberg is vice president of AMDA — The Society for Post-Acute and Long-Term Care Medicine and editor emeritus of Caring for the Ages. He serves as chief medical officer for Mariner Health Central in California and has been a nursing home and hospice medical director since 1995. He may be reached at [email protected] and he can be followed on Twitter @karlsteinberg.