There’s a stark beauty to winter trees. I’m fascinated by the intricacy of the branches that begin with thick, central trunks. They branch and soar and branch again, until there are thousands of delicate twigs pricking the chilled sky that surrounds them.
The anatomist in me can’t help but liken them to our own miraculous arterial system, that begins with a central aortic trunk and ends in feathery capillaries so fine they allow only single-file red blood corpuscles to deliver oxygen into the farthest reaches of our bodies. I like to think that William Carlos Williams, whose poem on winter trees I share below, might have noted these similarities as well. He was a 40-year career physician as well as an accomplished poet.
All the complicated details
of the attiring and
the disattiring are completed!
A liquid moon
moves gently among
the long branches.
Thus having prepared their buds
against a sure winter
the wise trees
stand sleeping in the cold.
As I enjoy the ubiquitous silhouettes of winter trees in the landscape this time of year, I ponder how we humans also prepare for the winter in our own lives. There’s quite a spectrum, to be sure, but ultimately, the infirmities of advancing age and the consequences of serious illness, which edit both our abilities and our mindsets, force us to consider what’s ultimately important.
Like winter trees, we frequently shed our leaves, the accumulated trappings of a well-lived life. My Mom, who is approaching her 91st birthday, has downsized several times in the last 5 years, intentionally simplifying her existence as her ability to maintain a household shrinks and her priorities sharpen.
In 2011, a group of medical researchers at Yale University School of Medicine published a study exploring older persons’ health outcome priorities. (Fried et al. Arch Int Med 2011;171:1854) They recruited participants from three senior centers and one independent/assisted living facility. 357 seniors were interviewed. The researchers evaluated the percentage of seniors choosing different priorities, as well as the strength of importance ascribed to each outcome.
Maintaining independence was the health outcome ranked as most important by 76% of participants, followed by pain and/or symptom relief as second, and staying alive as least important. These results surprised a number of folks (including a good number of physicians) who felt certain that seniors would consider staying alive to be their top priority.
Statistics on folks who request physician-assisted dying reveal similar findings. Longitudinal data from both Oregon and Washington State (the first two states to legalize physician-assisted dying) show that 90% of patients in both states are motivated to seek such assistance by a loss of autonomy. Loss of ability to engage in activities that make life enjoyable is a close second. In contrast, pain or concern about pain ranks near the bottom in the list of reasons.
To be sure, there are folks who rank staying alive as most important, a point that emphasizes the need for discussions about what’s uniquely important to each individual, as healthcare decisions are personalized to coincide with priorities. Developing a wide range of treatment options can help to increase the likelihood of desired outcomes, and decrease the likelihood of unwanted results.
Priorities evolve as our life circumstances and health circumstances change. Since we each have our own rankings, it’s important to share this information with family, health care providers, and personal caregivers. And, remember to update everyone concerned as our minds change and our motivations evolve.
The buds on a winter tree are prepared with hopeful expectation that spring will come and allow new growth, perhaps even flowers. In humans, our preparation for winter and readying for spring might be mindfully preparing our loved ones to prosper and blossom (after necessary and appropriate grieving) in a life without us.
Frequently, between the desire to remain independent and the desire to live longer, people with chronic serious illness rank relieving burdens on their families and strengthening meaningful relationships as important goals. Careful, intentional preparation aids well-earned winter’s sleep in both trees and people who stand resolute and peaceful in the knowledge that they have done their best.
At this point in my life, I ponder such thoughts from three different but intersecting perspectives. This year, I became a Medicare card-carrying senior myself. I’m thankful to be in decent overall health at this stage of life, though I’m increasingly mindful of the need for prudent self-care in my aging body.
Second, I’m fortunate to have an almost 91-year-old Mom, who teaches me by example every day. In the last few years, she has slowed visibly, and has made several intentional simplifications in her life. She readily shares her perspective on aging and health with everyone. Though she retains a wry sense of humor and acknowledges simple joys in daily existence, she misses the many cherished friends and family members who have preceded her in death. Living longer is certainly not a priority for her.
Finally, I can reflect on this topic as a seasoned physician. Decades in a primary care physician role have allowed me to hear the collective wishes of many patients and their families. More recent physician partnering with hospice patients and their families has enriched my perspective on the many shapes individually-crafted goals of care might assume—for uniquely right reasons.
In her book The Science of Older and Wiser, Phyllis Korkki states, “Wisdom: Maintaining positive well-being and kindness in the face of challenges is one of the most important qualities one can possess to age successfully.“
Let’s make one of our New Year’s intentions to reflect mindfully and wisely on our individual priorities so we might enter our winters with a sense of resolution and accomplishment. Additionally, let’s be mindful of the challenges of others whose lives we touch. Our gentle understanding and compassionate support can go a long way in softening transitions and dispelling fears.
Stephen L Hines, MD