The Two Forms of Triage

Wanting to live, or not, and the inverted flow of care.

Something that’s going on with me these days is that my mother is dying. It’s accelerating. I met the hospice nurse last weekend.

Local geography

Before Henry Hudson showed up, the locals called the Hudson River the river that flows both ways. When the tide comes into New York Harbor, the water flows north, toward the river’s source in the Adirondack Mountains. When the tide went back out, the river would resume flowing into the ocean.

All the effort and momentum that goes into living is like a river. Then one day, for some people, the flow reverses. And the river is no longer exactly a river. It doesn’t flow.

What is it then, an estuary? Like the East River, is it no river at all? Just a part of the ocean that became pinched between land?

Promise me

My mother had given up a while back. She turned down cancer surgery the May before last, when she could still drive, have meals in restaurants and shop. The treatment switched to palliative care.

In hindsight, this was always coming. When I was a kid, driving back to Massachusetts from a visit with my mother’s mother in Long Island, my mother would make me promise I’d put her out of her misery if she ever got to be like her forgetful, sometimes cruel mother.

I was nine years old, and wondered how that would even work. Would she write me a note? Even then, I knew it wasn’t a promise I’d be expected to keep.

Triage

I remember that word, strangely French for a sign in an emergency room in Worcester in the 1980s.

Triage is the first place you go in the ER. They decide how much help you need and how long you can wait, and prioritize you against the other sick and wounded.

In an ER, the worst off go to the doctor first. But in a battlefield, the triage order is flipped. The flow of care goes first to the ones with the best chances of surviving. When I was a teenager, I remember Kurt Vonnegut writing about this peculiar and very practical reversal of seemingly constant human values in the face of war.

Depression

Depression is so common these days that the word means almost nothing. It can come from anywhere. Things get too hard, you get discouraged, and withdraw. You spend more time in a fantasy world. Or else things get too easy, and you get bored. The victories and sweetness of life seem meaningless. Depression waits on both sides of a wobbly plank.

On either side, people often decide that the game isn’t worth the candle. Depression can lead to someone wanting to die. But wanting to die is different from depression.

Depression can be a statement made to the world, like going on strike. Depression can be a statement directed at you, like a Closed sign hung on every imaginable door. Wanting to die is quieter and more decisive.

Hospice

The nurse listed the medications my mother would no longer need - a few heart medications. Then she listed the handful of pain meds that would be increased at a moment’s notice to keep pace with my mother’s tolerance, and the increase in her pain.

End-of-life-care is hard to look at. It’s hard to understand because living depends in part on not understanding it. Mitigating pain while never getting better is not how anyone wants to think of the arc of our days.

But it’s there. You stop saying “feel better,” and start saying, “get some rest.”

Minutes like hours

The inversion of the survival instinct - and of all the impulses go forth upon the earth and be fruitful - seems like a sick joke. What makes sense of it is physical pain. It’s not easy to think while someone screams in your face. Pain erodes logic and warps time.

Time is the comedian who makes a joke of us. And time is always changing its tune. As you get older, time seems to pass faster. But then pain does something else to time.

Time ceases to fly. Each hour telescopes endlessly outward. We can all endure something, but none of us can endure absolutely anything. And when we don’t know how long a given discomfort will last, pain and time often compound one another into impossibility itself.

The shadow of decision

Pain shapes our lives. Pain is the silhouette of our actions. The memory of pain is the form of our opinions. A little more or less pain in a given situation at a given time may well have rerouted any of us.

Thanatos

A decisive desire for death is hard to recognize, simply because most people don’t even have a category for it. Everyone knows the eros of erotic, erogenous, erotica and so on. But fewer know thanatos.

Sometimes this desire to die is visible in the form of self-destructive behavior. But people are more often self-destructive for very lusty reasons - a frustration that life itself isn’t big, long or intense enough to meet our hopes and appetites.

If you’ve ever known someone who has decided to die, they may not exactly spring to mind. They are hard to think about. Once they decide, they can be nasty, seemingly unfair to their friends and loved ones. They can be dismissive, retiring, and deliberately unremarkable.