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

Michael Gordon MD, MSc, FRCPC is a geriatrician working at Baycrest Health Science System. He is medical program director of the palliative care program, co-head of the clinical ethics program and a professor of Medicine at the University of Toronto. He is the author of Late Stage Dementia, Promoting Compassion, Comfort and Care; Moments that Matter: Cases in Ethical Eldercare and Brooklyn Beginnings: A Geriatrician's Odyssey  

When I explain that I “look after older people,” I often hear, “Oh, that must be so depressing” or, “Isn’t that wonderful, you must be a special human being” and occasionally, “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 also direct a palliative care program, the responses are various iterations of, “dealing with death every day must be the most depressing thing a doctor can do, how do you do it?

To settle the issue, my geriatric and palliative care colleagues and I are neither saints nor masochists. Health care providers working in these areas are responsible, dedicated, committed and humane professionals. We all share much good humor while listening to the narratives and partaking of life’s pleasures and experiences as well as tragedies with our patients and families. We share the human experiences, individual fascinations, accomplishments, and disappointments.

There is a wide range of beliefs and values that older people and their families carry within them as they contemplate the latter period of their life. Sometimes they acknowledge that they are “close to the end” and do not want to prolong their life; they do not wish to risk suffering during the twilight of their life. There are many perspectives from which to view the universal human struggle about life and its deathward trajectory. There was a moving piece in the February 2, 2013, New York Times written by Louise Aronson, a geriatric medicine specialist at the University of California. In, “Weighing the End of Life” she focused on her aging dog and all the tribulations she faced deciding on when “enough was enough.” She eventually had this beloved pet put down. In the article she mused, “Since then, 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.” She finished her essay with the story of a very elderly man with many illnesses who refused hospitalizations. In her final sentence she writes, “He wanted to live — just not in the hospital, with poisons in his blood. He was sick and tired of feeling sick and tired. Like so many, his was a reasoned and reasonable stance.”

Reading her essay reminded me of a Dylan Thomas (1914-1953) poem published in 1951: Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light...Do not go gentle into that good night." The message is about fighting against life's end while acknowledging the difficulty and struggles with its impending termination.

At the time Aronson`s article, Pope Benedict XV1 at age 85, shocked the world by deciding to step down, the first such event in 600 years. There was speculation about the reasons and whether staying until his death would have been preferable while, “fighting against his age-related physical and emotional decline.`` For Time Magazine he wrote, “After having repeatedly examined my conscience before God, I have come to the certainty that my strengths, due to an advanced age, are no longer suited to an adequate exercise of the Petrine (Papal) ministry...this ministry, due to its essential spiritual nature, must be carried out not only with words and deeds, but no less with prayer and suffering. However, in today’s world...both strength of mind and body are necessary, strength which in the last few months, has deteriorated in me to the extent that I have had to recognize my incapacity to adequately fulfill the ministry entrusted to me.”

There is a contrast to the final years and months of Pope Jean Paul 11 who spoke with increasing frequency about his age, his failing health and death. The Vatican acknowledged that the Pope suffered from Parkinson’s disease only after his death, although the tremor in the Pope's hand became unmistakable in the early 1990s, and media references to Parkinson's disease abounded. Unlike Benedict XVI he was determined to stay at the helm until his end. "It is wonderful to be able to give oneself to the very end for the sake of the kingdom of God. At the same time, I find great peace in thinking of the time when the Lord will call me: from life to life," he said in a 1999 letter.

The last story reflecting “enough is enough” is the suicide note, reported in the February 8Canada’s Globe and Mail. Ruth Goodman of Vancouver, wrote, “I am a 91-year-old woman who has decided to end my life in the very near future. I do not have a terminal illness; I am simply old, tired and becoming dependent, after a wonderful life of independence. People are allowed to choose the right time to terminate their animals’ lives and to be with them and provide assistance and comfort, right to the end. Surely, the least we can do is allow people the same right to choose how and when to end their lives...I am writing this letter to advocate for a change in the law so that all will be able to make this choice."

Timothy M. Dolan, New York`s archbishop said, “By stepping down, the pontiff was saying, ‘my death is here; I feel weak, I feel fragile, I am frail.’" These words echo Ruth Goodman. For a Pope to resign might be akin to leaving this world or at least 'his world,' highlighting the notion that for many, a time comes when for their life and its meaning, “enough is enough."