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When Enough is Enough: Musings on the End of Work and Life

When I tell people that what I do professionally is “look after older people,” I often hear responses such as: “Oh, that must be so depressing;” or sometimes, “Isn’t that wonderful, you must be a special human being;” and on occasion, “there are so few of you—what will be in the future with so many old people using up health care resources?” When I add that I am also involved in palliative care, you can imagine the response, but usually permutations on the “dealing with death every day must be the most depressing thing a doctor can do, how do you do it?” Just think, combining looking after the elderly person in a palliative care setting might be interpreted by those who have never had to experience such a combination as the ultimate in depressing; something that only a “saint” or “medical masochist” would choose as a profession.

First, to settle the issue, my colleagues and I involved in the same domains of medicine are neither saints nor, for sure, masochists. In fact, I could say that for all the health care providers, such as nurses, occupational and physical therapists, social workers, dieticians, and pharmacists, undertake their professional responsibilities with dedication, commitment, and the utmost in humanity. They usually combine these attributes with an enormous respect and interest in the narratives, the family interactions, and ties that each of their patients bring with them, irrespective of their illness. Having spent a career undertaking many aspects of medical practice from Internal Medicine and all of its subspecialties, including intensive care, I have no hesitation saying that my colleagues and I probably share much good humor, laughs, life’s pleasures, and experiences, as well as tragedies with our patients and families. They all share a wealth of human experience with all its fascinations, accomplishments and disappointments.

Within this context it is worth considering the wide range of beliefs and values that older people and their families carry within them as they contemplate the latter period of their life. This may be combined with significant personal physical pain and psychological anguish. At times there is the clear acknowledgement that they are “getting close to the end” and do not want to prolong a life that they have long ago accepted as finite and do not wish to risk suffering during their very twilight days, weeks or months.

It was with this in mind that I was especially impressed by a few newsworthy items that seemed to address the universal human struggle about life and the trajectory towards death from different perspectives. First there was a very moving piece in the February 2, 2013, New York Times written by Louise Aronson, an associate professor of medicine and geriatric specialist at the University of California, entitled, “Weighing the End of Life,” which in fact focused on her aging dog and all the trials and tribulations she faced deciding on when “enough was enough.” She eventually decided to have this wonderful, loving, and loved pet put down. In the article she mused, “Since then (after the dog was euthanized), I have often wondered whether we waited too long. We counted the time he spent sleeping as contentment ... I know that in elderly humans, sleep is more often a sign of chronic exhaustion, depression, and avoidance of pain. In dealing with the guilt brought on by our mixed feelings — we love him; he’s ruining our lives — I realize we may have overcompensated to his detriment. With dying humans, similar situations arise every day: hospital stays that fix the