Delicate, fragile, frail: how we cope when we age

The insights and analogies that help.

Helen Cowan

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

An old woman wearing a shawl looks pensive.

Valentin Balan on Unsplash.

“Who could dissect a portion of the human frame without marvelling at its delicacy, and trembling at its frailty?” mused preacher Charles Spurgeon in the nineteenth century. Songwriters, artists, authors and surgeons alike are fascinated by frailty. Within, beneath and beyond that fragile frame though, could there be a deeper reality, waiting to arise – and endure?

Fragile Lives is the ‘heart-stopping memoir’, operation by operation, of heart surgeon Professor Stephen Westaby. “The finest of margins,” he writes, “separates life from death, triumph from defeat, hope from despair – a few more dead muscle cells, a fraction more lactic acid in the blood, a little extra swelling of the brain. Grim Reaper perches on every surgeon’s shoulder.”

To what shall we compare this fragility of frame? - which means we can shatter sudden as glass, our “breath becoming air” in the blink of an eye? (Paul Kalanithi, a young neurosurgeon, called his memoir When Breath Becomes Air as he fought his own battle with cancer). A snowflake? A spider’s web? A butterfly wing? In Dutch still life paintings, the transience of life is variously depicted in dry, fallen withering petals, rotting fruit, and a glass vessel, like a vase. At some funeral services, it is said that we are made from dust, and to dust we shall return. Elsewhere in the Bible, we are likened to a mist that appears for a little while and then vanishes, or to a flower that withers away, a fleeting shadow that does not endure. Our days are a mere handbreadth, our life but a breath, writes one Bible songwriter.

Medics talk more commonly of frailty than fragility – and it’s not just a byword for old age. According to the British Geriatrics Society, not all old people live with frailty; not all people living with frailty are old, though age is a recognised risk factor, with nearly 40 per cent of adults aged 85-90 being frail. Described as a vulnerability to external stressors which can result in sudden marked deterioration in function, frailty might feature as a combination of falls, immobility, delirium, incontinence, and increased side effects of medications, suggesting the body is struggling to cope. “A minor infection or minor surgery results in a striking and disproportionate change in health state – from independent to dependent, mobile to immobile, or lucid to delirious,” writes a team of doctors in The Lancet.

Frailty is a sign of advanced biological rather than chronological age. Often, it’s an unwelcome term, with consultant physician Patricia Cantley noting that, “from a patient or relative’s point of view, the word frailty seems to be at best somewhat vague and at worst, derogatory and demotivating”. She prefers to talk in terms of paper boats. Picturing young healthy patients as little tugboats of wood and steel, built to withstand storms, she likens the frail patient’s clinical situation to a paper boat, which can sail the sunny seas, but is soon buffeted and may be brought down by ‘medical winds’.

Encompassing also psychological and cognitive symptoms alongside the physical, frailty is not a fixed state, nor is decline in mind and body inevitable once frailty begins. Seen increasingly as a dynamic spectrum, reversal of frailty is sometimes possible; the paper boat being, to a degree, storm proofed and made to chart a different course. According to Dr John Travers, professor of public health at Trinity College, Dublin, twenty minutes of daily exercise can reverse physical frailty and build resilience in over 65-year-olds, while others suggest that movement based mind-body therapies such as tai-chi and yoga can strengthen both mind and body. Could there also be something of a spiritual strengthening in the frail patient? As the body decays and declines, could the soul, the spiritual self, enlarge, emerge and ultimately endure as life ebbs away? This was certainly the sentiment of Paul, one of the early church leaders, in the Bible, who, after much suffering, wrote: “Therefore we do not lose heart. Though outwardly we are wasting away, yet inwardly we are being renewed day by day…we fix our eyes not on what is seen, but on what is unseen. For what is seen is temporary, but what is unseen is eternal.”

Her late Majesty Queen Elizabeth II was seen on our television screens to diminish physically in her last days, her purple hands, tiny frame and walking cane causing concern among viewers. She was, at her funeral, described simply as “our sister Elizabeth”, her small coffin dwarfed by pageantry and a crowd of 2,000 including presidents and kings. And yet, the former Moderator of the Church of Scotland has revealed that she talked much of her Christian faith in her dying days, while her funeral was an explosion of scripture, hymns and sermons that expressed the strength of her personal faith. “It was her way of eloquently, beautifully and powerfully speaking to me and 4.1 billion other people of her Christian faith,” writes Pastor Skip Heitzig. For me, the funeral brought to mind the tides (continuing with the theme of the sea). As the tide recedes, the waters move away from the shore, in what is known as an ebb current. As the tide rises, water moves toward the shore in a flood current. As our Queen’s life ebbed away physically, her spiritual self arose, roaring like a mighty flood. Ocean motion, in currents, waves and tides, is driven by the sun, moon and the planets. Our late Queen also looked upwards, to her God, for spiritual succour that would turn life’s ebb to a soul-flood.

Hymnwriter Timothy Dudley-Smith sought a similar exchange, from the physical to the spiritual, the mortal to the immortal, in yet more words about boats, in his hymn “My boat so small”, based on the Breton Fisherman’s Prayer.

“Adrift when strength and courage fail, O Spirit, breathe to fill my sail”

And, happily, he trusts a safe voyage, finishing with - “My voyage done, all trouble past, to haven bring my soul at last.”

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Review

Ageing

Assisted dying

Culture

27 March 2023

5 min read

For love there is no charge

Out of mind old people are at the centre of Allelujah! Sian Brookes reviews the film adaptation of Alan Bennett’s play.

Sian Brookes

Sian Brookes is studying for a Doctorate at Aberdeen University. Her research focuses on developing a theological understanding of old age. She studied English and Theology at Cambridge University.

In a hall decorated for a celebration a person stands in front of a seated group, all have their arms raised in celebration.

Jazz hands at the hospital.

BBC Films.

Spoiler alert – this film review reveals significant elements of the plot.

Allelujah! is not a film that shies away from the big issues. In fact, you would be hard pressed to find a big issue this comedy/political commentary/drama/part-thriller doesn’t at least make reference to (and yes, it spreads itself across all of these genres too). With such an eclectic approach it is difficult at times to keep up with the narrative, and the deeper meaning of the film. Based on the Alan Bennett play, the plot centres around The Bethlehem, a small northern hospital for geriatric patients, which is facing closure due to the Tory government’s efficiency drive. It focuses on two members of staff, Alma Gilpin, a stoic and matter-of-fact but seemingly excellent nurse who has served the hospital her entire career, and a younger Dr Valentine. Other protagonists include an ex-miner patient and his son, a management consultant who has “made it” to London and is currently advising the Health Secretary to close hospitals such as the one in question for the sake of government finances.

Whether it’s politics or the personal, this film has it all. It deals with levelling up, the cultural and economic gap between the north and south, the challenges of budget cuts in the NHS, the problems of a national health service claiming to 'care' but with managers more preoccupied by Westminster’s economic priorities. It depicts families waiting for older relatives to die in order to grab their inheritance, the broken relationship between an ageing man and his son, and those all-important stories of the older patients’ lives well-lived. And yet as the story line develops, a plot twist emerges which comes to overshadow the entire film, and in the process speaks to what is perhaps the most poignant of the many discussions it raises. Nurse Gilpin, who, until now has appeared consistently caring and committed to her patients, has been quietly administering fatal beakers of milk and morphine to those who she deems to be on “her list” of those who most need relief from their situation. When confronted by the doctor she justifies her actions with a multifaceted answer based on the requirement to provide more beds to a broken healthcare system, but also insisting “I had ended someone’s suffering”.

When Dr Valentine remarks, “I like old people” a visitor responds “not even old people like old people”.

The manner in which Nurse Gilpin goes about what is effectively enforced euthanasia, is deeply chilling. And yet her reasoning is not entirely foreign to us – to end suffering could be deemed a noble cause. In fact, the need to simply delete the reality of suffering, particularly the suffering of the old is one that perhaps is not so uncommon. Throughout Allelujah!,we are reminded of our tendency to run from, to detest, to reject the suffering of the elderly in our society. When Dr Valentine remarks, “I like old people” a visitor responds “not even old people like old people”. A teenage intern declares to a patient “I hope I never live to be your age”. At the same time, characters look back on the days “when the elderly weren’t farmed out”, and questions are asked of families “if they love them, why do they put them away?”. A very good question. Of course, care needs are often too great for families to endure, yet it is still important to ask why the suffering of the old has become a professionalised service, which most of us avoid at all costs. Perhaps the answer to this is that we don’t like to watch the old suffer, we don’t like to watch them die, because their suffering and their death remind us of our future selves, our future suffering, our future death. In our sanitised, anything-is-possible-with-medicine-and-science society, death and the suffering that comes with it, is something from which we flee at all costs. Instead of acknowledging and working with it, we would rather pretend it wasn’t there at all.

And yet, even as we try to avoid it, suffering and death are both certain parts of all our futures. 100% of us will die. For Nurse Gilpin, the solution to this is to bring on death prematurely, to erase the pain, overcome the misery by offering a false hope – that it doesn’t need to exist at all. In direct contrast to this, in a film which is littered with Christian references (Allelujah, The Bethlehem), there is a different approach taken by a messiah-type figure who seems to get everything right. Dr Valentine is compassionate and understanding. He not only challenges the political systems which undermine those most at the margins of society, but also has the kind of bedside manner we would all hope for in a doctor. In a closing monologue Dr Valentine utters the words of the doctors in the NHS, “We will be here when you are old, and we would die for you, we are love itself and for love there is no charge”.

It is this suffering with which is so compelling, this suffering with which is truly sacrificial.

Nurse Gilpin and Dr Valentine offer two fundamentally different approaches to end of life care. One hastens the end quickly, deletes the suffering as efficiently as possible in order to make way for those in less pain. The other sits with those who suffer, holds their hand, gently cares for the human person that is in front of them. Even more, and perhaps most significantly Dr Valentine does not only watch from afar, but is willing to suffer himself for the sake of those in pain - working tirelessly, giving himself over day after day, fighting on with little sleep for limited pay just to make things a little less painful. It is this suffering with which is so compelling, this suffering with which is truly sacrificial, this suffering with which speaks of something much greater than politics, efficiency or inheritance, this suffering with which is indeed “love itself”, completely free of charge. This is the logic that Christians see in the ancient notion of the incarnation, celebrated every Christmas, of God with us. This is what our older people need, this is what we will all need when we grow old. Let us only hope that when we get there, we find the one who is willing to offer it.