Rage, Rage Against the Dying of the Light (Dylan Thomas)



They come into the ED after they have fallen down and can’t get up. They don’t eat or drink for a few days, a week, then get dehydrated and can’t take care of themselves.

They forget to turn off the stove. They leave the keys in the lock to to the outside door. It becomes too hard for them to bathe, so they simply stop bathing. They run out of food, but they don’t remember that one must go to the grocery store to buy more.

Email, their lifeline to the outside world and the family members that live in it, suddenly becomes stange and difficult to understand. Hitting the keyboard and yelling at the beige box become the only way they know how to express their frustration.

One glass of wine becomes two mixed drinks a night becomes half a bottle of wine becomes a fifth of liquor. The overt withdrawal symptoms seen in the emergency department are unexpected in a woman in her late seventies whose substance abuse history is “Not Applicable”.

The elderly account for a large number of visits to the emergency department each year. They come for falls, trips, slips, bruises, congestive heart failure, accidental poisonings, depression, confusion, and urinary tract infections. They have heart attacks, strokes, trouble breathing, headaches, visual hallucinations and chronic constipation.

They can be delightful people who bring a smile to the faces of their caregivers in the ED, or they can be someone’s worst nightmare (family or staff). They can command instant mobilization of resources, by virtue of the frightening acuity of their presenting symptoms. On the other hand, they can easily get lost in the shuffle and be pushed, literally, into a corner while squeakier wheels get the grease. 

Seeing elderly patients in the ED brings forth many emotions in me. I have pictures in my mind of family members, friends and patients from the past who inform my responses to the person in front of me. I won’t belabor the fine points of evaluating an elderly person with changes in mental status here, but I will share some insights with you that I have gleaned over the years. 

Old people have a lot to share. Youngsters, and even us middle-agers, sometimes tend to treat our elders as if they have given their best years and brightest ideas up and are just coasting through the rest of their lives. Not so. They are often very bright, very attentive to their surroundings and have much to say about the world around them. 

Old people tell great stories. No, they don’t do it in 140 characters or less. No, they don’t do it by embedding YouTube video clips in the conversation. They do it the old fashioned way. They paint delightful word pictures filled with satin and lace and fragrant hay fields and fishing ponds on a summer afternoon and tales of “the one that got away”. Be prepared to stay awhile. You can’t tweet a masterpiece. 

Old people remind us of where we’ve been. My own relatives, as they aged and faded out of my life, would often let me know that I shouldn’t forget where I came from. It was good advice then, and it’s especially good advice now, as many of us struggle for meaning in a cacophonous world.

Old people remind us of where we’re going. We will all age. None of us will get out of this alive. We can choose to ignore the wisdom that our elders have to impart, but at our peril. One day, we will be the one in the wheelchair or softly restrained to the gurney, trying to get someone’s attention. 

You are one day older today then when you read my post from yesterday. How will you age gracefully today? What will you learn? What will you give back?


“It`s not how old you are, it`s how you are old.” 

Jules Renard

8 thoughts on “Rage, Rage Against the Dying of the Light (Dylan Thomas)

  1. Greg,

    What a profound statement! “It’s not how old you are, it’s how you are old.” Yes, yes, yes!

    Two comments:

    First: Just about my favorite rotation in nursing school was at a nursing home (forgot the name…I’ve slept since then:/) in Atlanta near the Buckhead area. Nice. Clean. Great care given there. And I fell in love with this little old guy who happened to be my patient! My goal everyday was to get him to eat more than he did the day before!! And as a rule I was pretty persuasive at doing it. I learned to enjoy caring for the aged. The “caretaker” in me (because I have been that since I was eleven) really shined through.

    Second: another memory with an elderly patient was a few years after that. Surgical floor…post-op carotid endarterectomy…mean as HELL. She would curl your nose hairs. She would frighten Godzilla! My goal with her (as charge nurse & not student any longer) was just to get a smile. She was the most cantankerous I believe I have ever witnessed! But she was alive, vibrant, social, a force in her arena, sporting great authority. She had her first carotid cleaned (forgot to mention she was in for bilateral surgery) & came out beautifully. And with a smile!! I was elated! She was like a new person! I thought then, “She just needed some O2 to her brain!!” The day came for her 2nd surgery. I just knew she would feel even better. She had been talkative, smiling, even doing work from her bed (a socialite performing her social duties again). Someone had even come in to “Do” her hair! She was excited to get the 2nd surgery over with & get back to what she loved. And feeling much better as she did it. Well, you can see that something is coming here, can’t you? The day of her surgery we prepped her, talking & smiling about how it would be over soon. She was wheeled away throwing her hand up, yelling “Be back soon.” And then she was gone. Really gone. At least the way we remembered her. She threw a clot during surgery, suffering a severe stroke. She went directly to the ICU, never knowing anything ever again. My heart was broken. And I wept. For this elderly socialite, this controlling, demanding, even mean patient in 514, who I dreaded seeing everyday before her first surgery…I wept. Because I had seen just a glimpse of who she REALLY was. I saw a side of her that had been stolen by age, poor health & hypoxia. The side that her family & friends had come to adore. The side that I was only able to witness for 3 short days.

    My point is that this is the reason for most (and I do mean most…some are just plain out mean) of the bad behavior in our elderly patients. They have lost their youth. They begin to lose sight, hearing, mobility, agility, thought process…and they become cantankerous. They begin drinking a bit too much. They become recluse. They say things they would have NEVER even thought about saying in their better days. This lady (and yes, she WAS a lady!) taught me much in the week that I cared for her. Yes, they do teach us Greg. They teach us about the past. They teach us about the future. They teach us about “living!” We just have to listen really close sometimes, through all the static of their own personal “stuff.”

    Sorry this ran long. Good post, pal!



  2. When I first moved to NYC I lived at 128th and Lenox (Malcolm X)–smack dab in Central Harlem. And I loved it. I had some of the best neighbors. The highlight, for me, was joining the local gardening group. It was through the group that I met a lot of older folks. They were the best company. They’d tell me about the neighborhood back in the day–many of them had lived through some of Harlem’s toughest moments. I could sit on the stoop and listen for hours to stories about their families, their experiences in Harlem, and–for many–their experiences in the South. I learned a lot talking with them. I moved from the neighborhood 7 years ago and I miss the ‘hood and the people I met there. It was a special time.


  3. I love this, and wish more people understood. This is the very reason I’ve remained in geriatric care for 20 years. Sometimes I have to get out from behind the desk and go back out into the field and see patients just to remember these very things! Thank you for stating it so eloquently!


  4. Scorchy

    I very much miss the feeling of community that I remember growing up as a kid.
    I live in a complex now where I’m surrounded by people, but we rarely if ever interact.
    Sad but true.
    Sounds like you had a great community.



  5. It was nice there. The kind of neighborhood where your neighbors would yell hello from across the street. The neighborhood I live in now is not as familial, but there are the neighborhood locals, colleagues, friends, etc. that you bump into all of the time. I certainly have made more connections here than I ever had in the burbs.


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