A tiny Bella, wearing a striped sweater and a mostly toothless grin. My parents, glowingly happy with their new baby. My three great-grandparents, seemingly ageless.
My parents have a collection of pictures on their nightstand in a Rolodex-like stand, all dating to my earliest childhood. Throughout my life, I’ve flipped through the images in their plastic sleeves to be greeted by familiar scenes and beloved faces. In some of the earliest photographs, my great-grandparents stand in the unflattering light of a hospital room, looking the same in their seventies and eighties as they later would in their nineties.
My father’s mother’s mother was Mine to me, though she was Grandma to everyone of my dad’s generation. She would live into her early nineties, eventually dying in a nursing home, without her children, grandchildren, or great-grandchildren near her. She had earned her nickname in a tug-of-war game we played when I was a toddler. We pulled a stuffed animal back and forth between us, each claiming it as “Mine!”, and that became her name. By the time she died, she would not have been able to play such a game — she had developed severe Alzheimer’s and could not speak, let alone remember me.
Mine could relish an In-N-Out burger as well as a night at the opera, even if she would vehemently deny the former. She was sophisticated and staid, with hair as perfectly coiffed when she was in the nursing home as in pictures of her in the 1940s. In these two photographs, she wears a smart skirt suit and a draped dress. She gazes away from the camera. This degree of distance and disengagement was apparent when I knew her, too, and she remained a sort of elegant relic in the present day. She belonged to an era and a lifestyle that feels almost like a fairytale today, and I got fewer stories from her.
My mother’s grandparents are similarly emblematic of a bygone era, but in quite different ways. My mother’s mother’s father was called Popie, my uncle’s childhood attempt at Papou, the Greek word for grandfather. The nickname is appropriately evocative of Popeye, the lanky, animated sailor with an affinity for spinach: Popie did eat a lot of spinach, was in the US Navy and later Merchant Marines, and sported tattoos from his service during World War II. Ever active, Popie passed away in 2016. He walked the dogs and worked in his garden until a few months before his death.
His wife, my mother’s mother’s mother, who is currently living in a nursing home, is YiaYia Choo-choo. YiaYia is Greek for grandmother, and the suffix was my addition as a toddler (in part to distinguish YiaYia Choo-choo from “normal” YiaYia, my grandmother): when I went to their house, we would read train-related stories or play with train toys, and so she became indelibly associated with trains.
Popie and YiaYia were both the children of Greek immigrants who came through Ellis Island at the turn of the last century and settled in San Francisco. From Popie especially, stories abounded. He was born in 1920 and lived in South San Francisco. His family owned a small bakery, called the Eagle Bakery, that did not even have a bread slicer. He didn’t get his own toothbrush until he was ten years old. He was a Pearl Harbor survivor. After the war, he married my great-grandmother and became a truck driver. He loved to travel and made a rather grand excursion every year—he rode the Trans-Siberian Railway, visited Australia, and went to his favorite place in the world, Victoria Falls, several times.
Popie was incredibly sharp and remained so until the very end; he would tell stories about his first grade teacher well into his nineties, thanks to both a remarkable memory and narrative skill. He was stubborn, opinionated, and had a scathing sense of humor. I recently found a note that he sent my mother around 2013, just to say, “Why is it New Yorkers feel that paying 5 dollars for an overpriced California avocado makes it nutritionally superior to a 50 cent avocado from an outlet store? Provincialism? Try battin’ that one outta the park with your Fungo [bat].”
YiaYia, in her own words, is still “hanging in there.” She turned ninety-five on June 1, though she guessed that she was turning thirty. She has dementia and has been in a nursing home, bedridden, since early 2018. She has always been a bit more enigmatic than Popie, but her mild demeanor belies her sweet tooth, sense of humor, and endurance.
Born in 1926, she is older than the Golden Gate Bridge, which she walked across with her elementary school class on the day it opened. YiaYia grew up during the Depression and came of age in the post-war period, and her recipes prove just how exciting prepackaged foods must have been: her chocolate cherry bars call for one package of Pillsbury fudge cake mix, one can of cherry fruit filling, almond extract, and two eggs. She has scores of characteristic responses to questions — “That’s good,” “Keeping busy,” and “Hanging in there” all make regular appearances. I often wonder what worries, delights, or interests her.
Nursing homes are pervaded by a distinctive scent of disinfectant and death. Some patients have cards and pictures above their beds or visitors crowded around, but the majority are alone. Their small corners are unadorned, their beds separated from their neighbors’ by a mere curtain. These are oppressively lonely rooms, connected by bleak hallways, empty save for a rare, mobile patient in a wheelchair, or a nurse in maroon scrubs.
I still remember the shoes I was wearing the first time I visited a nursing home—the last time I saw Mine in the summer of 2013. Lime green flip-flops were not the wisest footwear choice. Mine had severe Alzheimer’s, and, since we had last seen her a few years earlier, she had gone from being completely coherent to entirely nonverbal. I don’t recall exactly when she was moved to that facility, but I will not soon forget my once regal great-grandmother lying withered under scratchy, white sheets. But her hair, a brighter white than the bedding, was still fluffy and pristine.
YiaYia has been in a nursing home since early 2018, and I saw her there for the first time in April 2018. For as long as I can remember, my parents urged me and my siblings to see every goodbye to Popie and YiaYia as potentially our last. That expectation of loss was so emphasized that it began to feel absurd, as, every year, my great-grandparents were still there to give us hugs and birthday cards. But, that April, the sense of finality was profound. I cried in the small, beige-walled room, though I carefully turned away from YiaYia so she wouldn’t see me cry.
Nursing homes are where people go to die. Their occupants are generally elderly, though sometimes younger; they cannot remain at home, and they are not expected to recover or leave.
Hospitals likewise can be places of anxiety, pain, and loss, but they are also places of hope—a hospital has an admixture of death and birth, illness and recovery. I find great solace in that range of human experience. The sharp lines of lengthy hallways, the muted tones of adult wards and farm animal stickers in pediatric wards, all provide a comforting sense of order. The beeping of machines speaks of sickness, but also of technology and progress.
Even labor and delivery wards are the sites of tragedy; the NICU is an especially heart-rending place. But, when I have visited the NICU, no babies have unadorned incubators. Every crib seems to have a card, a drawing, a parent at its side. Though I have cried by the elevators outside the NICU, as I have in nursing homes, the sense of sorrow is a rather different one.
Even in the NICU, there is a promise, however tenuous, of a whole life to be lived. The stunning medical progress of recent decades is evident — if my younger brother was born in my parents’ generation, he would not have survived his first weeks of life. But nursing homes exude a crushing futility. They reek of solitude and prolonged death, without the whiff of hope, community, and love that are more readily apparent in other medical settings.
Nursing homes have been flawed from their very foundations. In his book Being Mortal, author and physician Atul Gawande describes the origins of nursing homes. In the mid-twentieth century, hospitals became increasingly prevalent, and subsequently there was an efflux of elderly from poorhouses to hospitals. But these poor, elderly patients had chronic conditions, and new units were built for them — the origin of modern nursing homes.
In nursing homes, Gawande writes, “regimented, anonymous routines cut us off from all the things that matter to us in life” (9). Safety, productivity, and medicine have become paramount in caring for the elderly, rather than what matters to the aged, within or outside nursing homes (Dugdale, Gawande).
Nursing homes are particularly oriented towards promoting safety and medical treatment over more holistic care. The consequences of these priorities were devastating during the Covid-19 pandemic. The physician Lydia Dugdale lamented the suffering of the elderly in the midst of the pandemic, as “They have slowly died over this past year in isolation and loneliness. And we caused it — ‘to keep them safe.’”
Even when a patient has an attentive and loving advocate, like YiaYia Choo-choo does in my grandmother, care in nursing homes is highly variable and sometimes abysmal. Certain nurses or attendants won’t put in her hearing aids, because it is too much trouble; rather than promoting her well-being in a small but significant way, they allow her to languish in an auditory fog. Even this is a relatively minor issue in a system that promotes efficiency and medicalized treatment over individuals’ well-being and basic care.
Popie never ended up in a nursing home. He passed away in November 2016, the day before his 96th birthday, just a few months after being diagnosed with pancreatic cancer. He stayed at home while he started chemo, but he moved to the VA after a little while, where we saw him for the last time over the week of Thanksgiving. We would sit in a small lounge on his floor while he slept (I know exactly which books I read sitting there), and, when he was awake and up for it, we would go in and spend time with him.
He was as loquacious as ever, though he tired more easily. He had my grandfather (his son-in-law) shave him regularly — his hands were too shaky for him to do it himself, but he was not one to let himself go, even as he was dying. He got along famously with his social worker, with whom my grandmother has spent time since then. He was determined to make it to his birthday at the end of the month. He didn’t, quite. Nearly five years later, I still miss him dearly.
But what strikes me about his death is the extent to which he was surrounded by care and community. He had agency over his own care, thanks to my grandmother and his social worker. He quickly decided to stop chemo to retain his quality of life, and he was able to step back from that treatment. That he received care at the VA was itself a reminder of a significant part of his life in the military. And he had opportunities to tell stories about his childhood as he lay dying— one of a shrinking group of Pearl Harbor survivors, a child of the Great Depression, a deeply loyal South San Franciscan and Greek-American. He was regularly visited by the three generations that came after him, to whom he was father, grandfather, and great-grandfather.
Popie was far from perfect, but his life and death provide an exceptional model of a life well-lived and well-died. He had a staggering range of experiences in life and lived nearly a century, with perfectly intact mental and physical health for over 95 years. He died mercifully swiftly, though, of course, physical health and death cannot be controlled.
End-of-life care — the slow or swift process of dying — should aim to help people die well, just as they have lived well. Dugdale draws upon Christian Wiman’s idea of “dying into life” in her account of how to prepare for a good death, through a good life: “we should grow in our relationships, in our cultivation of virtue, in our understanding of what gives our lives meaning. Dying into life leads to survival not annihilation.” That survival can look like Popie’s impact on me and my family, an impact he had on his deathbed and continues to have posthumously.
Ultimately, we should strive for our elderly to die more like Popie — with dignity, control, and community, after a life well-lived. And, even now, we can strive to live our lives well in the honest and essential but ultimately joy-promoting awareness that our days are limited.