Morning Zen Guest Blog Post ~ Mary Elizabeth Murphy Rauktis
On a warm and brilliant October afternoon, my mother fell as she crossed the street to the New to You consignment shop, intent on retrieving the cane she’d left behind while browsing. While her body would eventually heal, her mental health would come to resemble that cane: it, too, was a thing she would try to recover but never manage to reclaim. In the months after she tumbled to the cement, her carefully constructed world would shatter like the bones in her hip.
“Who will take care of me?” she asked repeatedly after her surgery. “What will happen to me?” Unable to be reassured or comforted, she wept inconsolably, as if she were suffering from a pain more terrible than the aches brought on by her physical injuries. When this emotional wildfire had finally blazed through her, it was replaced by a depression so profound that there was nothing recognizable of her left. By January the mother I knew—the one who was always looking for a party or to play with Barbies with her granddaughter, the one who could get a complete stranger at a bus stop to tell their life story—seemed to have already died. In her place sat this elderly stranger, pretending to be my mother. This other-mother didn’t smile or laugh; she had no interest in her children or grandchildren; she didn’t want to see her friends. Her all-consuming obsession with her physical health convinced her that she was going to die at any moment. I didn’t like this other-mother. I wanted my real mother back.
I am a child welfare researcher, and I’m skilled at collecting and analyzing information in order to understand problems. I decided to apply the same method to try to understand what happened to my mother, and what could be done to make her better. My search revealed that about a quarter of geriatric patients die within weeks after a hip fracture, and of those who do survive the surgery and the rehabilitation and physically recover, about a third will become moderately to profoundly depressed. This, in turn, interferes with the person’s daily functioning, creating a vicious cycle of depression and physical deterioration that leads, eventually, to death. With a history of depression that began with a hospitalization when she was thirty-five years old, my mother was particularly at risk. This was before I was born, but by talking with my sister, who was about seven at the time, I could piece together some of what had happened to her during that first depression.
My mother had become depressed and delusional, convinced that she was dying, and her functioning deteriorated to the point that she couldn’t take care of my sister. There weren’t a lot of treatment options available for depression in the 1950s. As was typical treatment for the time, she spent several months in a state hospital and received electroconvulsive therapy (ECT), one of the few available therapies for depression at that time. The ECT worked—she improved and was discharged from the hospital. She would struggle with a chronically low mood throughout her life, but she never had another episode of depression that required hospitalization.
As she aged, however, events she’d previously been able to cope with—a short period of illness, a long and cold winter that kept her confined to her apartment—now seemed to trigger periods of depression and hopelessness. She was on an antidepressant when she broke her hip. It was as if she had been treading water until that day: not reaching the shore, but not drowning, either. She was overwhelmed by the accident, by the tsunami of trauma, surgery, pain, anesthesia, and disrupted routine that followed. She couldn’t keep head above the water anymore.
Since I had a medical and research background, my older sister and brother were depending on me to figure out what was going on and what to do. But I could never quite pinpoint whether the depression stemmed from the accident and its subsequent traumas, or whether the event had exacerbated an existing condition. The research did tell us that if we didn’t act and get her into the hospital soon, her functioning would continue to deteriorate, and she would probably die. She agreed to go to the hospital, and her doctor admitted her to the psychiatric unit. I hoped that a new medication, perhaps one of the newer classes of anti-depressants, would restore her to a state that resembled the one she was in before she fell.
But not all mental health problems are so easily solved. My brother called me one day to talk about her.
“What do you think? It’s been four weeks, and she looks the same—maybe even worse. Why isn’t it working?” he asked. I had been wondering the same thing, my concern deepening. And I was feeling guilty. I was the one who had recommended hospitalization.
“I don’t know. She’s starting to have tics and problems walking. I think it’s from the medication—sometimes it has side effects that look like Parkinson’s disease.”
“What else can they do?” he continued. Underlying the conversation was a shared but unspoken concern: what if this is what she is going to be like forever?
“I don’t know, but I’ll talk to her doctor,” I promised. Something had to be done. She had to be fixed.
“Your mother isn’t responding to the antidepressants,” the geriatric psychiatrist said, “and if I increase them any higher, the side effects will get worse. I think a course of bilateral ECT is the next course of action. It can sometimes be effective when medication fails, particularly for the elderly.”
“When can you start?” I asked.
The process of ECT involves sedating the patient with general anesthesia and a muscle relaxant, then sending an electrical current through the electrode pads on one or both sides of the head, creating a seizure. Although the causal mechanisms are not fully understood, the procedure is believed to somehow reboot neural functioning in parts of the brain. If changing the chemicals in her brain through medication didn’t work, perhaps ECT would restore her nervous system back to something approximating normal. I hoped it would be just a matter of finding the right combination of ECT and medication.
Why did it matter so much? In the past, our relationship had been characterized by my contempt for her helplessness and passivity. I’d wanted her to stand up for herself when my dad bullied her; to have an opinion; to encourage me to leave home, go to medical school, and see the world. She wanted me to be a nurse, have children, and stay in Pittsburgh, preferably within a city block of the family home. She was dismayed by my choice to focus on career rather than family.
Our mutual disappointment in each other was our only common ground for years—until my daughter Olivia was born. My mother loved her extravagantly. She could play with her for hours, helping her to painstakingly dress and accessorize her Barbie dolls; and I know she let Olivia eat cotton candy and Klondike ice cream bars before dinner, because my daughter would confess to me when she later refused to eat. But while I may have complained, I really didn’t mind. She was enjoying her granddaughter, and I felt joy in watching this process. I also hoped she might see that I was striving to be a good mother, a better daughter, and a more generous human being. I needed her to get better so we could continue on this path. I wasn’t ready to stop, and there was no way I could do it without her.
“We have to fill out these papers; they need them before you have ECT, Mom. They want to know what they’re allowed to do if your heart stops.” The hospital had asked me to complete her “advance directives,” instructions on what they were permitted to do in case she experienced an event, such as a heart attack or stroke, while in the hospital. “Do you want life-sustaining equipment like ventilators and respirators? Do you want them to do CPR on you? What about food and fluids—do you want a feeding tube?”
Even at the time, I recognized the irrationality of asking these questions: her thoughts were so disorganized that she couldn’t choose between the cherry Jell-O and the rice pudding on her Presidents Day-themed lunch menu. I watched her gaze out of the window at the snowy park. Her hair, uncombed and flattened in the back from months of lying horizontally, was in desperate need of a trim. She picked at her sweater with her ragged and yellowed nails. I wasn’t sure whose sweater she was wearing. I laundered her clothes and returned each item—her initials, “PM,” indelibly inked on it—but ownership of clothing appeared to be optional on the psychiatric unit.
“I don’t want to be in pain,” she said.
“This isn’t about pain medication—this is about what you want done if something happens while you’re here, if your heart stops and you can’t speak for yourself. The hospital wants to know what they are allowed to do,” I repeated.
Impatient, I looked down and scanned the ranked options for keeping someone alive, checking “no” for feeding tubes and respirators, “yes” for minimal actions like IVs and blood, wishing all the while that one of my siblings was having this conversation instead of me. I am the youngest. Why wasn’t birth order working in my favor? I resented the hours I’d spent watching her sit and stare sightlessly out of the window overlooking the emergency helicopter pad, time taken away from my students and work, hours stolen from my husband and daughter. I wondered if she even wanted to be alive, and the thought filled me with equal parts of rage and resentment. She has a good life, one worth fighting for, I thought, and she doesn’t care. How could she give up so easily? She just wasn’t trying hard enough.
“I don’t want to be in pain . . . I don’t care what you let them do to me, but promise me that you won’t let me suffer,” she said.
It was the most coherent sentence she had spoken in months, and she looked at me—really looked at me—for the first time since she’d broken her hip. I wondered if the frustration, resentment, and anger that had been building up in me over the past four months were now so evident that she feared I would let her suffer as punishment.
“I won’t let you suffer,” I said, giving the assurance as casually as if I had promised to bring her favorite slippers from home. I had no idea how difficult this promise would be to keep.
The ECT did give her a period of remission from the depression, but the window of time was short. We watched a lot of TV together during that brief period, especially the game show Jeopardy. Ken Jennings, who would ultimately go undefeated for seventy-four consecutive games, was the reigning champion, and she enthusiastically rooted against him, loudly urging the other contestants, particularly the women, to “kick his butt.” I enjoyed watching her cheer for the underdogs—my mother, the late-blooming feminist. It was something new, and fun to see.
Nothing specific happened to cause her depression to reoccur, but within ten months she was back on the psychiatric unit. Each time I saw her she was less engaged, more internally focused on her anxiety, sadness, pain, and fear for what would happen to her. More disturbing, she was becoming increasingly confused. She realized this, and it increased her anxiety exponentially.
I could hear her sobbing when I was buzzed through the locked doors that led to the psychiatric unit. She was always sitting next to the nurses station, where the nurses parked all the “problem” geriatric patients in their wheelchairs in order to keep an eye on them. In my mother’s case, it was her confusion and anxiety that made her a problem and a falling risk. My petite mother could slip, Houdini-like, out of the more comfortable vest restraints, so they had to use wrist restraints instead. Her wrists were bruised from her pulling at them, as were her heels, which she would bang against the wheelchair’s metal footrests. The nurses regularly apologized for the restraints, explaining, “We have to do that or she will get up and fall. She’s so agitated, so confused. Nothing is helping to calm her down.” Medication did not help, and her ECT was discontinued because it only increased her confusion and agitation. There was nothing to be done but send her to a long-term dementia unit in a nursing home. She couldn’t be fixed.
I was losing my mother and failing to keep my promise. And my belief in the empirical process of medicine, its ability to diagnose and cure, was deeply shaken. I wasn’t letting her suffer due to my anger, but because of my incompetence. I couldn’t figure out what was wrong. No matter how much I pored over the research, looking for descriptions of this blend of agitation, confusion and depression, I couldn’t solve the problem. I could no longer concentrate at work, either, my sole refuge, and I began to think that maybe I, too, was losing my mind. I needed some help.
“So you made a promise that she wouldn’t suffer. What makes you believe that you have the power to prevent suffering, pain? Are you God?” The therapist to whom I’d been assigned had quickly become directive during our second session. “You no more have the power to change this situation than you have to alter the course of the Ohio River. We all want an easy death, but no human has the power to grant that wish. Get over that delusion, grieve, and find a way to make your peace with this situation.”
This was tough. It would not be so easy to give up the delusion that I could control the circumstances of her death. Yet it also relieved me of some of the guilt that had made it difficult to be with her—and equally difficult to be away from her.
I still hadn’t accepted the situation when, one November evening, I was sitting next to her bed in the nursing home, looking out the window at the abrupt fall of darkness that happens after turning back the clocks. She awoke, looked at me, and said, “Mary, you need to go home; you have a long way to drive and it’s dark and Olivia will be wondering where you are.” I realize now that she was giving me permission to get on with my life. I didn’t know that it would be the last time my mother would speak directly to me, using my name.
My mother died on a brilliant and cold January afternoon while in hospice. I received the call at work, and after calling my brother and sister, I made a quick stop at home before walking to the corner where the school bus would drop off Olivia. We walked home together.
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Mary Elizabeth Murphy Rauktis is the author of one of the essays in the book Writing Away the Stigma.