Authors: Atul Gawande
That was just the opening Thomas needed. Halbert hadn’t said no. Over a few subsequent meetings, Thomas wore him and the rest of the team down. He reminded them of the Three Plagues, of the fact that people in nursing homes are dying of boredom, loneliness, and helplessness and that they wanted to find the cure for these afflictions. Wasn’t anything worth trying for that?
They put the application in. It wouldn’t stand a chance, Halbert figured. But Thomas took a team up to the state capital to lobby the officials in person. And they won the grant and all the regulatory waivers needed to follow through on it.
“When we got the word,” Halbert recalled, “I said ‘Oh my God. We’re going to have to do this.’ ”
The job of making it work fell to Lois Greising, the director of nursing. She was in her sixties and had been working in nursing homes for years. The chance to try a new way of improving the lives of the elderly was deeply appealing to her. She told me that it felt like “this great experiment,” and she decided that her task was to navigate between Thomas’s sometimes oblivious optimism and the fears and inertia of the staff members.
This task was not small. Every place has a deep-seated culture as to how things are done. “Culture is the sum total of shared habits and expectations,” Thomas told me. As he saw it,
habits and expectations had made institutional routines and safety greater priorities than living a good life and had prevented the nursing home from successfully bringing in even one dog to live with the residents. He wanted to bring in enough animals, plants, and children to make them a regular part of every nursing home resident’s life. Inevitably the settled routines of the staff would be disrupted, but then wasn’t that part of the aim?
“Culture has tremendous inertia,” he said. “That’s why it’s culture. It works because it lasts. Culture strangles innovation in the crib.”
To combat the inertia, he decided they should go up against the resistance directly—“hit it hard,” Thomas said. He called it the Big Bang. They wouldn’t bring a dog or a cat or a bird and wait to see how everyone responded. They’d bring all the animals in more or less at once.
That fall, they moved in a greyhound named Target, a lapdog named Ginger, the four cats, and the birds. They threw out all their artificial plants and put live plants in every room. Staff members brought their kids to hang out after school; friends and family put in a garden at the back of the home and a playground for the kids. It was shock therapy.
An example of the scale: they ordered the hundred parakeets for delivery all on the same day. Had they figured out how to bring a hundred parakeets into a nursing home? No, they had not. When the delivery truck arrived, the birdcages hadn’t. The driver therefore released them into the beauty salon on the ground floor, shut the door, and left. The cages arrived later that day, but in flat boxes, unassembled.
It was “total pandemonium,” Thomas said. The memory of it still puts a grin on his face. He’s that sort of person.
He, his wife, Jude, the nursing director, Greising, and a handful of others spent hours assembling the cages, chasing the
parakeets through a cloud of feathers around the salon and delivering birds to every resident’s room. The elders gathered outside the salon windows to watch.
“They laughed their butts off,” Thomas said.
He marvels now at the team’s incompetence. “We didn’t know what the heck we were doing.
Did, Not, Know
what we were doing.” Which was the beauty of it. They were so patently incompetent that most everyone dropped their guard and simply pitched in—the residents included. Whoever could do it helped line the cages with newspaper, got the dogs and the cats settled, got the kids to help out. It was a kind of glorious chaos—or, in the diplomatic words of Greising, “a heightened environment.”
They had to solve numerous problems on the fly—how to feed the animals, for instance. They decided to establish daily “feeding rounds.” Jude obtained an old medication cart from a decommissioned psychiatric hospital and turned it into what they called the bird-mobile. The bird-mobile was loaded up with birdseed, dog treats, and cat food, and a staff member would push it around to each room to change the newspaper liners and feed the animals. There was something beautifully subversive, Thomas said, about using a medication cart that had once dispensed metric tons of Thorazine to hand out Milk-Bones.
All sorts of crises occurred, any one of which could have ended the experiment. One night at 3:00 a.m., Thomas got a phone call from a nurse. This was not unusual. He was the medical director. But the nurse didn’t want to talk to him. She wanted to talk to Jude. He put her on.
“The dog pooped on the floor,” the nurse said to Jude. “Are you coming to clean it up?” As far as the nurse was concerned, this task was far below her station. She didn’t go to nursing school to clean up dog crap.
Jude refused. “Complications ensued,” Thomas said. The next morning, when he arrived, he found that the nurse had placed a chair over the poop, so no one would step in it, and left.
Some of the staff felt that professional animal wranglers should be hired; managing the animals wasn’t a job for nursing staff and no one was paying them extra for it. In fact, they’d hardly had a raise in two or three years because of state budget cuts in nursing home reimbursements. Yet the same state government spent money on a bunch of plants and animals? Others believed that, just as in anyone’s home, the animals were a responsibility that everyone should share. When you have animals, things happen, and whoever is there takes care of what needs to be done, whether it’s the nursing home director or a nurse’s aide. It was a battle over fundamentally different worldviews: Were they running an institution or providing a home?
Greising worked to encourage the latter view. She helped the staff balance responsibilities. Gradually people started to accept that filling Chase with life was everyone’s task. And they did so not because of any rational set of arguments or compromises but because the effect on residents soon became impossible to ignore: the residents began to wake up and come to life.
“People who we had believed weren’t able to speak started speaking,” Thomas said. “People who had been completely withdrawn and nonambulatory started coming to the nurses’ station and saying, ‘I’ll take the dog for a walk.’ ” All the parakeets were adopted and named by the residents. The lights turned back on in people’s eyes.
In a book he wrote about the experience, Thomas quoted from journals that the staff kept, and they described how irreplaceable the animals had become in the daily lives of residents, even ones with advanced dementia:
Gus really enjoys his birds. He listens to their singing and asks if they can have some of his coffee.
The residents are really making my job easier; many of them give me a daily report on their birds (e.g., “sings all day,” “doesn’t eat,” “seems perkier”).
M.C. went on bird rounds with me today. Usually she sits by the storage room door, watching me come and go, so this morning I asked her if she wanted to go with me. She very enthusiastically agreed, so away we went. As I was feeding and watering, M.C. held the food container for me. I explained each step to her, and when I misted the birds she laughed and laughed.
The inhabitants of Chase Memorial Nursing Home now included one hundred parakeets, four dogs, two cats, plus a colony of rabbits and a flock of laying hens. There were also hundreds of indoor plants and a thriving vegetable and flower garden. The home had on-site child care for the staff and a new after-school program.
Researchers studied the effects of this program over two years, comparing a variety of measures for Chase’s residents with those of residents at another nursing home nearby. Their study found that the number of prescriptions required per resident fell to half that of the control nursing home. Psychotropic drugs for agitation, like Haldol, decreased in particular. The total drug costs fell to just 38 percent of the comparison facility. Deaths fell 15 percent.
The study couldn’t say why. But Thomas thought he could. “I believe that the difference in death rates can be traced to the fundamental human need for a reason to live.”
And other research
was consistent with this conclusion. In the early 1970s, the psychologists Judith Rodin and Ellen Langer performed an experiment in which they got a Connecticut nursing home to give each of its residents a plant. Half of them were assigned the job of watering their plant and attended a lecture on the benefits of taking on responsibilities in their lives. The other half had their plant watered for them and attended a lecture on how the staff was responsible for their well-being. After a year and a half, the group encouraged to take more responsibility—even for such a small thing as a plant—proved more active and alert and appeared to live longer.
In his book, Thomas recounted the story of a man he called Mr. L. Three months before he was admitted to the nursing home, his wife of more than sixty years died. He lost interest in eating, and his children had to help him with his daily needs more and more. Then he crashed his car into a ditch, and the police raised the possibility of its having been a suicide attempt. After Mr. L.’s discharge from the hospital, the family placed him at Chase.
Thomas recalled meeting him. “I wondered how this man had survived at all. Events of the past three months had shattered his world. He had lost his wife, his home, his freedom, and perhaps worst of all, his sense that his continued existence meant something. The joy of life was gone for him.”
At the nursing home, despite antidepressant medications and efforts to encourage him, he spiraled downward. He gave up walking. He confined himself to bed. He refused to eat. Around this time, however, the new program started, and he was offered a pair of parakeets.
“He agreed, with the indifference of a person who knows he will soon be gone,” Thomas said. But he began to change. “The changes were subtle at first. Mr. L. would position himself in bed
so that he could watch the activities of his new charges.” He began to advise the staff who came to care for his birds about what they liked and how they were doing. The birds were drawing him out. For Thomas, it was the perfect demonstration of his theory about what living things provide. In place of boredom, they offer spontaneity. In place of loneliness, they offer companionship. In place of helplessness, they offer a chance to take care of another being.
“[Mr. L.] began eating again, dressing himself, and getting out of his room,” Thomas reported. “The dogs needed a walk every afternoon, and he let us know he was the man for the job.” Three months later, he moved out and back into his home. Thomas is convinced the program saved his life.
Whether it did or didn’t may be beside the point. The most important finding of Thomas’s experiment wasn’t that having a reason to live could reduce death rates for the disabled elderly. The most important finding was that it is possible to provide them with reasons to live, period. Even residents with dementia so severe that they had lost the ability to grasp much of what was going on could experience a life with greater meaning and pleasure and satisfaction. It is much harder to measure how much more worth people find in being alive than how many fewer drugs they depend on or how much longer they can live. But could anything matter more?
IN
1908,
A
Harvard philosopher named Josiah Royce wrote a book with the title
The Philosophy of Loyalty
. Royce was not concerned with the trials of aging. But he was concerned with a puzzle that is fundamental to anyone contemplating his or her mortality. Royce wanted to understand why simply existing—why being merely housed and fed and safe and alive—seems
empty and meaningless to us. What more is it that we need in order to feel that life is worthwhile?
The answer, he believed, is that we all seek a cause beyond ourselves. This was, to him, an intrinsic human need. The cause could be large (family, country, principle) or small (a building project, the care of a pet). The important thing was that, in ascribing value to the cause and seeing it as worth making sacrifices for, we give our lives meaning.
Royce called this dedication to a cause beyond oneself loyalty. He regarded it as the opposite of individualism. The individualist puts self-interest first, seeing his own pain, pleasure, and existence as his greatest concern. For an individualist, loyalty to causes that have nothing to do with self-interest is strange. When such loyalty encourages self-sacrifice, it can even be alarming—a mistaken and irrational tendency that leaves people open to the exploitation of tyrants. Nothing could matter more than self-interest, and because when you die you are gone, self-sacrifice makes no sense.
Royce had no sympathy for the individualist view. “The selfish we had always with us,” he wrote. “But the divine right to be selfish was never more ingeniously defended.” In fact, he argued, human beings
need
loyalty. It does not necessarily produce happiness, and can even be painful, but we all require devotion to something more than ourselves for our lives to be endurable. Without it, we have only our desires to guide us, and they are fleeting, capricious, and insatiable. They provide, ultimately, only torment. “By nature, I am a sort of meeting place of countless streams of ancestral tendency. From moment to moment … I am a collection of impulses,” Royce observed. “We cannot see the inner light. Let us try the outer one.”
And we do. Consider the fact that we care deeply about what happens to the world after we die. If self-interest were the
primary source of meaning in life, then it wouldn’t matter to people if an hour after their death everyone they know were to be wiped from the face of the earth. Yet it matters greatly to most people. We feel that such an occurrence would make our lives meaningless.
The only way death is not meaningless is to see yourself as part of something greater: a family, a community, a society. If you don’t, mortality is only a horror. But if you do, it is not. Loyalty, said Royce, “solves the paradox of our ordinary existence by showing us outside of ourselves the cause which is to be served, and inside of ourselves the will which delights to do this service, and which is not thwarted but enriched and expressed in such service.” In more recent times, psychologists have used the term “transcendence” for a version of this idea. Above the level of self-actualization in Maslow’s hierarchy of needs, they suggest the existence in people of a transcendent desire to see and help other beings achieve their potential.