Curtain Up! Act III

No one can really imagine the future. Jesus tried it. His version of the final act of the world is reported in the thirteenth chapter of the Gospel of Mark. Jesus’ “Little Apocalypse” unfolds in a modest black and white; Mark by and large eschewed special effects. But a wide screen technicolor blockbuster of the same followed half century or so later in the Book of Revelation that closes the New Testament with a bang.

What Jesus and the author of Revelation were attempting was to picture for themselves (and us) Act III of the cosmic drama that was our world, a drama that many Jews of that era felt was drawing to a close. Jesus’ version (or maybe it was Mark’s) was not particularly original; the Old Testament prophets had pretty much covered the same ground. It was not a pretty picture in any event. With its whirling stars and shifting planets, Jesus’ imagined picture of the End Time must have put a chill in its audience, even before Matthew and Luke added some grim details from the Roman sack of Jerusalem in 70 A.D. But all’s well, as the saying goes, that ends well. The shock and awe that opens the cosmic Act III end with the Son of Man –that’s Jesus— descending on clouds of glory to gather the elect and usher them in to the Kingdom.

But Jesus, begging your pardon, made the not unusual mistake of being too specific in his prediction: this dramatic, almost operatic Act III called “The End of the World as We Know It,” would unfold, he promised, if not in the lifetime of those listening, then certainly in the then current generation. But it didn’t. It still hasn’t.

Jesus had a message and a mission, apparently modest at first –his fellow Jews were Jesus’ own target audience— but it eventually broadened out to include “all the nations,” with a rather grandiose Act III fashioned out of the Jewish apocalyptic tradition. Most folks don’t walk upon that stage, of course. If we have a mission or a message, it is modestly parochial, to cure cancer, perhaps, or end war. And we have pretty much gotten over the chumps’ game of trying to imagine or predict the end of the world. Our own final act will unfold, we know, within more homely parameters.

What, we wonder, is going to happen when Act II, my current adult and functioning lifetime, comes to a close and the curtain goes up on Act III, “The End Time”? Will there be a soft landing, a gradual and graceful decline with no diminution of my faculties until, one day, no, better, one night, I gently expire in bed; or, even more wishfully, I breathe my painless last in a four-poster surrounded by my quietly weeping loved ones. Or will I –God forbid!– be attacked by a brain-devouring microbe or a nasty aneurism and writhe my way off stage in unbelievable pain? Cancer maybe, the ambiguous prostate variety or the deadly pancreatic? Do I have the courage to imagine dementia? Ten years of worrying about my Dominican aide stealing my money, or wandering into the street in my Haynes underwear?

Jesus attempted to hedge his End Time prediction with “No man knows the day or hour.” It’s a useful meme for our End Time as well. Our personal Act III may open suddenly, with a stroke perhaps, or a heart attack, a crippling accident or an out of the blue diagnosis: “I’ve looked at your charts, sir, and I’m afraid you have a brain tumor.” “What?” The sudden and severe damage of a stroke or cardiac arrest imposes a severe necessity on the years that follow: an enfeeblement of limb or speech or movement degrades life to an unanticipated degree. A cruel accident in the night and Act III begins in Intensive Care, or worse, under the cold lights of an operating room. Patches are applied: a pacemaker, a prosthetic limb, insulin injections, the sad slavery of dialysis; the punitive sentence of chemotherapy. It is a grim, irresistible fate, this headlong fall from health that comes to an unpredictable few.

For most, the curtain goes up more slowly. Sometime in my still glorious 60s –“The new 40s!”— I begin to experience a slight but noticeable failing of body and memory that must have occurred when I was not looking: a fugitive name, face or phone number; an unconscious grasp of the bannister going down stairs; more light on the newspaper, more volume on the TV; the pill container with the irremovable cap and the now illegible dosage instructions on the side; a lump in the breast, blood in the urine, a fall on the sidewalk, skinned hands and knees but nothing more, “Thank God!” But whether the curtain goes up with a start or slowly, Act III will inevitably begin.

We prefer not to imagine the catastrophic descent into Act III, and we are incapable of imagining the slower and far more mysterious journey that leads, we know not for how long or over what uncharted landscape, from full functioning adulthood to our end.

There is, of course, a grudging admission that we must die, though buried deep in the psyche there seems to be a completely unfounded and obviously delusional escape clause. As noted above, we have no difficulty imagining our dying –many hours at the movies provide a rich archive of images from which to compose our own self-serving version of the gently named “passing.” What gives us trouble, however, is figuring death itself. Oblivion may in fact be unimaginable for conscious beings.

It is a trifle macabre attempting to picture one’s own death, but it is a useful exercise, with practical familial and financial consequences, to attempt imagining the run-up to the final tableau, the interval between the point when the first bone creak, false step or forgotten appointment signals what the Greeks called the peripeteia the point at which the dramatic action begins to unravel, and the mortal moment when we expire: Exit protagonistes, and that same curtain, with its pastel scenes of our first date, the honeymoon in St. Thomas, at work amidst admiring colleagues and rolling a wheelbarrow of cash out of TIAA-CREF headquarters, slowly descends on the melodrama of our lives.

The narrative flow of the final act of life is disturbingly unpredictable, as if the playwright had left off composing and surrendered Act III to the blind vagaries of chance, the disabling changes in health –why me?– which, if they occur, dictate radical alterations in lifestyle. Catastrophic events like a stroke or a serious accident obviously trigger an immediate and radical alteration in the way we live: one or other of us will end up (temporarily) in rehab or (permanently) in a nursing home far earlier than we might expect or hope in our Old Age. There is, however, no reckoning that kind of bad hand with its cruel consequence: our autonomous life in a private home is abruptly transformed into one of total dependence in an institution not of our own choosing, delivered into the hands of others, perinde ac cadaver, as Ignatius of Loyola put it of his obedient Jesuits, “just like a corpse.”

The mind turns away from such fierce imagining. It is not so much that we cannot imagine it for ourselves; it is that we will not do so, except perhaps in passing in the dentist’s office or at Motor Vehicles, and then with a shudder. “No” (another delusion), “that’s not for me. We, all of us, prefer the alternative, the gradual decline, smooth and peaceful in its transit, elegant in its execution, into, well, the Passing. There are such Acts III, I am sure, but they occur most often in our imagining; the actual Dramaturgist of our lives is a realist (or as some say, a brutalist) who is not much given to Happy Endings.

It is not difficult to discover how long our Act III will last. If we can supply the date of Curtain Up, the merest of insurance agents can provide our Closing Date from his actuarial files. “Let’s see, you were seventy when you slipped and fell inside the Apple Store in Soho –By the way, do you need a lawyer? I passed the bar— and I have you passing at eighty-seven years and three months…”

Not to worry, it’s only your actuarial death, when a statistician in Connecticut predicts you will die. On the other hand, his predictions are so accurate that insurance companies have grown rich betting on them. But as we know, nothing we’re told about averages ever applies to us; we’re as unique as an angel. Let us suppose, however, just as an exercise, that the number-cruncher has got it right and that you, we, have seventeen years between our first unmistakable intimation of mortality –“Wait. I’m OK. Nothing’s broken.” –and our death, actual, not actuarial. What happens during that long Act III?

It is here that our imaginations fail us. We have no way of filling in that very extensive blank. Most of us, I’m guessing, think of our adult life, Act II, going on pretty much as before, with occasional bumps, until a final illness carries us off. Perhaps it seems so, but with that first fall, or however else the signal is given, we have, willy-nilly, put our foot upon a slippery slope that now leads precipitously downward. There will be other falls, just ask our statistician, new attacks on an immune system under siege, an unexpected fainting spell, a sudden jump in blood pressure, a newly discovered melanoma –“Just one night in the hospital. Routine.”—arrhythmia, leukemia, diabetes.

These are bumps, to be sure, but they are far more consequential than the bout of flu or the strep throat that provided comic relief in Act II. The dominant theme in Act III is debilitation, a deterioration of function. There will be a new parade of painful episodes, one or other of which will eventually and inevitably become life threatening. Our life is now interrupted by unexpected late night trips to hospital emergency r1ooms. We learn how to spell gurney. There are new more painful procedures: a colonoscopy –“Just relax. You’re going to sleep through this,” – or, on the flip side, “It’s called a catheter, sir. It will sting a little when I introduce it.” “Yikes!” X-rays are now replaced by inquisitive body scans, all searching for that terrible thing that will steal our lives from us. Medicare becomes our favorite government program: a generous benefactor that reaches out an institutional arm and plucks a four- or five-digit hospital bill from our quaking hands.

Scary stuff that, but they are only episodes; in between are long stretches –our insurance man did say seventeen years— of trying to cope with the troubling conditions that now beset us. We are still at home, of course, with short trips, it may be, to the hospital emergency room and with longer but still finite stays in the hospital to deal with what ails us. Hospitalization is Act III’s new fact of life. But when we are discharged, that is not the end of it. There follows us home on occasion a cohort of “health providers,” who are the inescapable sign of things to come: a visiting nurse to monitor our new debilitated state; a physical therapist who attempts to restore some strength to our weakening limbs; and an aide who is an exact measure of our new condition: he or she will help clothe, feed and wash us as required.

The aide, like the nurse and therapist, are regular but occasional visitors, and their help –thank you again, Medicare— does not go on indefinitely. What if we need continued monitoring, therapy and assistance? How do we cope, especially if we are living at home alone or with a coeval spouse incapable of rendering that assistance? Here it is, the first ominous fork in the road, not a choice between Athens or Jerusalem or between the Way of Light and Way of Darkness but even more consequentially, whether to move in with relatives –daughters of America, step up!— who will help maintain their new guest as best they can, or else to relocate to an Assisted Living Residence.

The fork in the road image, with its suggestion of a thoughtful, chin-stroking choice, is misleading, however. The choice may very well not be ours, but will rather belong to a healthier spouse or a younger sibling or, more often than not, someone who stands a generation behind us, a son or a daughter, who decides whether we are to come to stay or will be, let’s state it cruelly at this point, institutionalized.

The first alternative, moving in with a relative, is daunting for both parties, for the new guest who must adjust to living, on sufferance, in someone else’s house –“Where the hell are my things?” You call this breakfast? Cheerios?”– even if one of those someones is your own offspring. And what about that other silently pensive onlooker, your daughter-in-law, let’s say, the one who dishes out the Cheerios and has her own parents waiting in the wings?

This new nesting is only temporary, however. The health of Mom or Dad will eventually deteriorate –there’s no convenient timetable here; just inexorable nature– beyond the powers of the offspring to cope, no matter how well intentioned, and we, yes, it’s us, will be outsourced to one or other of the second alternatives. The first of them is, or rather, was, an Independent Living Community, senior residences, condo ownership with a variety of housekeeping, social and medical services and, inevitably, a golf-course. That train has, alas, already left the station; you should have gone to Arizona and clambered aboard five years ago. The other alternatives are more practical: in order of ascending need (and descending hope), an Assisted Living Residence, a Nursing Home and, let’s not go here, a Hospice. Medicare, which for most of us is where a hospice bill gets paid, defines it as a health facility for those with six months or less to live. Let’s not even try to imagine that.

With the Assisted Living Residence we enter the natural habitat of the Old, or better, the Very Old since the merely Old are still out there cycling, doing Pilates, working through an organic tasting menu. But not to worry; they will join us shortly. The merely Old are also misleadingly displayed in the glossy brochures produced by the Assisted Living residences, couples all tanned and fit, laughing in the sunshine, entertaining friends as tanned and fit as themselves. They inhabit the cushy brochures –senior porn– but these California models are nowhere to be found in the Assisted Living residences. Who actually live there are the Very Old, who are neither tan nor fit, and couples are very few and far between in those halls. Most of the residents are in fact solitary women.

And here you are in their midst. How and why did that happen? Why it happened is much easier to answer. You, we, were incapable of taking care of ourselves in critical matters. We lacked the strength or the flexibility, or perhaps even the will, to perform certain basic tasks: feeding, washing, dressing or medicating ourselves. Reading the Times and watching TV no longer suffice as a lifestyle. We know the game is up when we cannot even drag ourselves around the corner to our favorite French restaurant. So pack up your unguents and moisturizers, Mr. Metrosexual and Ms. Now, because, like the dog who thought he was going off to be “tutored,” you’re going to take a little trip.

How it happens is more complex since there are other players. To boldly generalize: it will not be you who initiates the move to Assisted Living; you may agree, perhaps cheerfully, perhaps reluctantly, but it will not your idea. The decision is, in effect, a rejection of the first alternative, moving in with a relative, or, if that was initially chosen, the recognition that it no longer works: wife, daughter, sister –sorry, it’s the way of the world– can no longer cope. And again, it’s relatives who find the place, and whether it’s your money or theirs that is going to pay for it may determine not only the choice of residence but also how much say you have in the final decision. But it’s eventually made. Some small fraction of the possessions that represent the infrastructure of your life are packed up in cartons marked Act II, and you are transported, not like the Son of Man, on clouds of glory, but in a car service, to your new home.

We cannot imagine the sequel, or perhaps prefer not to, but let us try. No one has so far reported back on the Afterlife, but there are enough Assisted Living reports to give us an idea what’s in store. Let me add here my own. The newcomer to the Kingdom of the Very Old may be somewhat startled; I certainly was. The average seventy- or early eighty-year-old is not much exposed to the Very Old since these latter are stashed away in their daughter’s guest room or, as here, cloistered in Assisted Living. First, they are in fact very old, almost all of them nonagenarians or centenarians, most with failing eyesight and badly failing hearing. Don’t expect a lot of complex or prolonged conversation here where the shout is king and repetition is the very soul of wit. For many, the unassisted walk is a distant memory. The Very Old are mobility challenged: the strolling companion of preference is now an aluminum walker, and the chief conveyance, a wheelchair. Former boulevardiers take notice: bring your own.

The living is, as advertised, assisted. You have your own furnished room, with a bathroom but no shower. Showers are administered twice weekly in an egregiously named “Spa Room.” The help are cheerfully helpful. Your room is cleaned daily, the bed is made, the sheets and towels changed. Waitresses trained in patience serve three meals a day in the residence dining room: assigned places, four to a table, vacated walkers parked helter-skelter all over the room. Breakfast is to order; there are menu choices for dinner and supper. The food is institutional good: filling, lightly seasoned, no frills, no surprises.

Though not designed as such, these three daily mealtimes and the half hour or so conversations that pass between me and my three tablemates are the entire sum of my social life; all other resident encounters, most of them friendly, are glancing and insubstantial. I did not choose my dining companions, nor is there any evidence that they were selected according to some well-intentioned plan. We were all apparently plunked down as chance or occasion dictated.

Perhaps it does not matter. I look around the dining room. There are thirty-five very old women and five very old men. Two of the men are loudly garrulous, cackling and guffawing; a couple of the ladies are talkers: one seems to be continuously whispering what must be gossip, and the other is just plain daffy: she broadcasts, to no one in particular, a steady stream of inane information. For the rest, they are bowed and silent except to announce that they didn’t order -–they did— the food that has been set before them.

It’s not as if the institution doesn’t try to stir the synapses. There is a daily exercise class, various games and craft “activities,” most of them cruelly dumbed down to fit, I suppose, the skills and interests of the Very Old. In-house entertainments are scheduled (local performers and the inevitable Elvis impersonator), as are shopping trips to the local Walmart and the Dollar Store. There are also regular in-house religious services, all of them now chummily ecumenical since most of the Very Old are now long past caring about confessional identities. Those who wish it are carried off to church –I suspect it matters not which one— on a Sunday morning.

Life unfolds, a new life without markers. Retirement has half prepared me for this: holidays have become insignificant; weekends cease to exist. Birthdays are celebrated here somewhat routinely and in a minor key; meaningful somehow without being joyous. It is an oddly carefree life: there are no assignments, no bills, no due dates, no financial or even social crises. The Very Old cut each other considerable slack, perhaps because they realize that the other has lost a few marbles or, more likely, because they’ve forgotten what the argument was all about.

Health is the only real issue now. How long can I stay in what I know is a holding pattern? The house doctor visits the residence once a week and pays an individual room visit as required or requested. He is professionally interested but not terribly involved. It could scarcely be otherwise; his elderly patients are all inherited transients: they enter with long medical histories; they depart, unpredictably and suddenly. He is briefed by the floor nurse, listens to heart and lungs, checks pulse, temperature and blood pressure and writes prescriptions for the countless pills of various sizes, shapes and colors that are dispensed every day before breakfast and after upper
The house doctor is essentially a monitor; the heavy lifting is done by outside specialists, an array of gynecologists, cardiologists, urologists, oncologists, and there are scheduled visits –transportation is provided– to their offices around the city. These are the first team; one or other of them will enable me to live carelessly forever or –need it be said?— will deliver the bad news that will direct me to the building next door, the Nursing Home that is the setting for the sad coda of our Third Act.

This is a dark view, but necessarily so when viewed from the sunny perspective of Act II. No one wants to finish his life in this fashion, bed- or wheelchair-ridden, attached to tubes or probes, incontinent and sad. But the inhabitants themselves of nursing home are not necessarily so. The halls of well-kept nursing homes smell of neither death nor despair. Those who live there seem neither happy nor obviously unhappy, merely resigned or accepting of their condition. Their pain, such as it is, is alleviated; they are washed, fed, clothed and medicated. But they will never leave, nor will we.

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