78.79

Brittany Buchholz

Old age is a privilege easily wasted in denial. May we live deeply—yes! And in doing so agree, too, to eventually die.
          —Anonymous

“Diffuse, lymphangitic lung metastasis.”
          Christina and I heard the four words as the budding leaves crept like green fingers through the Rocky Mountain Aspen. Nothing like news of your own timeline to make a sugar-free latte seem flippant. All this while we sat cross legged in the hospital room, nursing Starbucks from the downstairs lobby. Was there really a time we’d thought it was the simple carbs that would kill us? I was a dietitian working at a nursing home, and thought it to be the most suspect contender. That, or bone-in chicken.
          The average United States life span is 78.79 years.¹
          At 28, the cancer tiptoed through Christina for two years, decorating each room of her body with no regard for her tastes. Onward it meddled: breast, bone (sternum, pelvis, cervical spine), liver. Somehow, in the two years since her first diagnosis, we’d been able to know the words yet ignore its presence. Life had not changed for her, for us, except the shit that was biweekly chemotherapy. It was the type of presence that created a tilt, but not a complete turn of identity. She’d kept her hair, still chose sequins, stilettos, still the one to turn heads and get drinks bought for her at a concert.
          When she vomited at our reservation-only Manhattan bistro dinner table, the waiter assumed it was from the bottle of Cab Franc. We were happy to let him. She continued to expel out the midnight cab window, accelerating to a halt at each stop light, and we’d accost scrutinizing sidewalk spectators: “It’s cancer! Stop judging!” Something about the fact we’d leave them behind with a green light meant we could tell them. Practice saying it. Her reality could be out of her belly and into theirs, and just as soon, we’d be gone. Laughing. Timeless, before the prognosis.

“Have they spoken to you about bone-in chicken?”
          I’ve been asked the question ad nauseum by Colorado state surveyors for the three years I’ve worked in nursing homes. The surveyor’s black suit is formal, but even she can’t help but turn up the corners of her mouth at the necessarily serious tone. Below a stiff collar, her name badge glistens, gold rimmed. Each time a resident calls in a complaint, they must come out to conduct a formal investigation. These are the rules indicated by Medicare and Medicaid.
          “I’m not authorized to approve it. They could choke.” My throat tightens around the unfair anxiety welling inside. I hate defending myself for simply using common sense.
          “Have you explained this to them at the residents’ council meetings?”
          “Yes. Many times.”
          “Because it isn’t in their meeting minutes.”
          I had no clue anybody was taking minutes.
          She hasn’t looked up at me as she scribbles notes on a clipboard. I can’t see beyond the tilt of it, but I get the feeling it says “elderly abuser,” or something similar.
          Something is certainly being harmed here, and it probably is the elderly, but not at the hand of the facility. It’s more than that: the healthcare system. Funds for Medicaid/Medicare. Reason. Life.

“Sorry to interrupt.” The pulmonologist in starched white knocked while entering her hospital room. He was young, with dark features, a chiseled stature accustomed to commanding respect. Appropriate age range, handsome, and a physician: Christina’d probably matched with him on Tinder at some point. They always swiped right for her. She was a traditional beauty: tall, elegantly built, and thoughtfully dressed. Her wardrobe was a careful combination of feminine fabrics structured by striking accessories: delicate lace dresses with metal-studded sandals, hair easily falling in waves held back by pushed up cateye sunglasses. Still, anyone could dress well. Christina had that something special. Her eyes sparkled as they scanned a scene, and you realized she noticed everything. She saw. She saw people, her surroundings, the smallest details. And she passionately, carefully, savored it all.
          “Your aura is so vibrant,” an interviewer once told her. She was offered her job as a high-ranking solar sales professional on the spot. She’d wondered if the man was hitting on her, but I knew better. You couldn’t help but reflect her light back at her. She was lit from within, and those around her drew in close to that fiery glow. In Christina’s presence you were not quite safe, not quite warm, but electrified. Alive.
          “Who do we have here with you, Christina?” The pulmonologist asked.
          “Oh—we’re swingers.” She motioned to me and Casey, her boyfriend, who coughed on his latte at the thought of a sensual escapade with me, her friend of seven years, bony-nosed and twenty pounds chubbier yet five inches shorter.
          The starched man’s lips quivered with the effort to form a smile. That’s when I knew. Sugar-free vanilla, now sour with stomach bile, teased the bottom of my throat.
          “I have a few things to review with you. Do I have your permission to speak freely in front of them?”
          “Yes.” The room stilled as Christina lassoed his gaze, pulling the space between them taut.
          She had that effect on men: light and easy, until threatened. Then, careful. Calculating. She had the determination of an ox, carried with the grace of a heron. She was intimidating in that way. Especially to a doctor used to hierarchy. This man was not a specialist, but a sow at the end of her rope.
          “I’ve read over your history, but we’ve never met, so I thought maybe you could start by telling me about your journey with cancer. What do you understand to this point?”
          “I don’t think that’s necessary. You have all my records.”
          It was not her job to buy him time. Not her job to soften his edges. He let out air.
          “I’ve looked at the scans, Christina, and unfortunately I don’t think this is pneumonia.”
          He began talking, his words blurring into the mint green walls. They had an eggshell finish, thick and porous enough to absorb both sound and air. “The outlook is not good. I’m so sorry.”
          He offered a case manager to speak with her about “goals of care.” She declined.
          “Please let me know if there’s anything I can do for you.”
          “There is. I’ve just met you, and you’ve only told me bad news. But you haven’t given me any good news. Please tell me two pieces of good news before you leave this room.”
          That was our Christina.
          He was a fly pinned to a board as she straightened against the plastic headboard. Tall for a woman at 5’9”, even seated she could be statuesque. The physician squirmed, shoulders caving with the impossible demand.
          “Well,” he looked to me, buying time. I had nothing for him.
          “You’re young. You’re young, and it might not seem like it but your organs are strong. Your heart is strong. You’ll endure this all better than an older person might.”
          She stared at him. Into him.
          “And,” his eyes scanned Casey, pleading him to contribute a silver lining. But Christina didn’t want a silver lining.
          She wanted him to take it back. She wanted him to take it back. She wanted to see every country. To turn her travel stories from forty-nine countries into a book. To have a child someday with the eggs she’d froze prior to the start of treatment. What would happen to them, tiny half-lives of hers left in a freezer without their physical mother? It had never occurred to her to ask.
          “It appears you have some very good friends to support you. I can tell they care for you, and they are going to help you through this.”
          His words, weightless, were sucked in by the walls along with the rest.
          “Alright. Thank you. You can leave, now.” Her eyes left him and moved to the door, dictating his next move.
          He hesitated in silence, then left. How lucky, I thought, for this world of open robes and beeping machines to end for him at the hospital doors. He couldn’t have been more than a couple years out of residency. He’d talk about this that night with his wife, about the girl his own age whose death sentence he had to deliver. His wife would comment, sympathetically. Furrow her brow and sip wine. “I can’t imagine,” she’d likely reflect into her plate, then turn conversation to weekend plans in Aspen.
          Christina pulled down her sleep mask, slumping back into doubled-up thin white blankets. Casey and I fumbled into our cell phones, a silent understanding between us. We were googling.
          “Please don’t google!” they say. “Write down any questions you have, and either I or the social worker can answer them.”
          But of course you do. If the prognosis is good, the doctors can’t wait to share. But when it’s hopeless, they don’t say anything at all. Even if you drum up the courage to ask How long?, you understand that the warm body of them cannot speak the truth to the equally pulsing body of you. It’s not like the movies. The cell phone is the only unbiased reporter. Its search engine is indifferent to you or your soft, porous flesh. The flash of gold flecks in your otherwise grey iris, the neon purple paint on your toenails. The phone gives it to you straight. It is the only one who can.

Generally, pulmonary lymphangitic carcinomatosis responds poorly to chemotherapy and shows poor prognosis, and it is well known that approximately 50% of the patients die within 3 months after its diagnosis. ²

          We were thirty-two.

          “Suzanne, we can’t serve it,” I plead. “If somebody choked, we’d be responsible.”
          She’s one of my favorite residents. She doesn’t leave her room without her large-rimmed black plastic-framed glasses, a long double stranded pearl necklace, and a teased auburn toupee. Late eighties and proud, she carries herself with poise.
          They surround us- me, the administrator, and the Foodservice Director, forming a semi-circle. We’re outnumbered in the stoning pit.
          “That’s a goddamn lie! It’s because you’re all cheap!”
          These words aren’t Suzanne’s, rather a gentleman with brown-spotted skin and thick glasses, yellowed enough to make his face unmemorable. Still, I don’t recognize him. He’s thin, clavicles protruding under crepe skin. His belly stretches to harbor a basketball. Cirrhosis. He must be a newer admit. Has he even been here for a full menu cycle? How have they already recruited him to the mutinous cause?
          “It’s not about the cost. We go over this every month, you guys. It’s about your teeth.”
          Well, gums.
          “The chef has offered to roast whole chickens, and debone the meat before serving it if you’d like that.”
          “Phooey! It gets dry!”
          “I’m sure he can make gravy if you’d like.”
          Roger, a tube-fed resident, throws a pen at me. Toward me. It barely falls off his table. But by the red determination of his face, I know what he meant to do.
          “Bullshit!” Roger calls out. “We’ll see what State has to say about you idiots!”
          He pushes back and turns the wheels of his chair toward the door, signifying that Resident Council is over. Behind him rolls an IV pole with a bag of tube feeding formula dripping into his stomach. One-thousand, eight-hundred ninety-six calories, and eighty-three grams of protein per day. It meets exactly 108% of his daily estimated needs and satisfies the Daily Recommended Intakes for vitamins and minerals. We politely avoid eye contact as his chair carries him away too slowly. I consider giving him a push, but decide that’d only make this worse for him.
          A man should be able to storm away on his own four wheels. Eight, if you count the IV pole.
          His voice carries from the nurse’s station outside the cafeteria door. “Hello! This is 911? I need to report these g’damn idiots!” This will be the third 911 call this month from the halls of our nursing home.
          I tell myself fibs about this job, things to keep me coming back day after day. Things to make me feel less useless, more a part of the health care team. When I was greener, I’d tried all sorts of things: Healthy Eating Club, Recipe of the Month, even Ask a Dietitian, a column submitted weekly to the in-house newspaper.
          It was all bullshit.
          They just want their damn bone-in chicken. But I can’t approve it for the menu. If they choke on a bone, The state surveyors would bury us. I repeat it to myself, and it only becomes more absurd with each playback.
          I can’t approve the only meal that ninety-year-olds desperately want to eat, because by eating it they could die.
          The average United States life span is 78.79 years.
          Those folks must be eating too much bone-in chicken.

The marquis flashes its destination: Istanbul, Turkey. Chests fluttering, we take a seat and wait to board. My N-95 moves in and out with each breath, airtight. That’s comforting. I look around, eyeing other passengers—some masked, some noses out, some masks hanging from ears. The lady beside me sneezes into her hand, then reaches her fingers back into her vending machine bag of Cheetos.
          I can see the COVID crawling bright orange across her fingers.
          Please don’t lick them.
          Christina is unbothered, mask dangling by one ear and buried in her cell phone.
          “I booked us the hot air balloon with a private champagne party to follow. It was a little pricier, but … sunrise champagne? Come on.”
          She coughs weakly at the end of her sentences. Hers isn’t COVID, I know. I wish those around us did, too.
          Her doctors had insisted she keep an oxygen tank with her, but she’d have none of it. I wish I could shield her from the suspicious looks, wish I could flash them a sign: NOT THE VIRUS! JUST DYING ANYWAY! But they’ll never know.
          She’s as magnetic as ever, even in travel leggings and a loose, gray T-shirt and low-top sneakers. An oversized Louis duffle distracts from her too-thin, bony shoulder. Sandy blonde locks sweep easily into a low pony. Even bare-faced and with a growing slight gray shade, she has the kind of dewy skin that sells makeup. “The foundation that looks like you’re not wearing anything!” She’s one of the very few people who actually isn’t, but you’d still buy the primer, foundation, and the setting spray all on her recommendation.
          The plane taxis. I lean back and close my eyes, dozing away from the sounds of the jet engine and into the deep, concerned voice of my husband. His pleas not to go. His accusations of recklessness.
          “She’s lost it, Brittany! You want to see a high-risk poster child? She’s on chemotherapy and immunosuppressives. She can’t breathe as a baseline. She has a life sentence, and is not thinking. I don’t blame her. But you do not have a life sentence.”
          Don’t I? Don’t you? Don’t all?
          I move the food around my plate, making a mental note to change the too-harsh bulbs of the dining room pendant light.
          “Have you looked into the restrictions? If she gets it, they won’t let her back in. She’ll miss her treatment. Brittany- she’ll die there! Alone, in Turkey. Away from everybody who loves her. Who even knows her!”
          He’s a hospital physician, in the middle of a deadly pandemic peak, annoyingly authoritative on this topic. But I know, and he knows, that we booked the nonrefundable tickets for a reason. Still, he says what he must.
          “That’s why I have to go with her. She can’t go alone, and you know we aren’t talking her out of it. I wouldn’t leave her, Justin. I’d stay with her.”
          “You could get it! You could get it, and she wouldn’t stay there with you! She couldn’t. She has to be back for treatment. You could be stuck in Turkey. You could die alone! Young people are dying from this virus too, you know. I just had a guy … ” I couldn’t decide if his tone was condescension or desperation. It was easier to decide the former, so I could rally in opposition. But now that it plays again, I’m feeling something like guilt as I hear the cracking in his voice. It was just his job to tell me “no.”

“I’d like to speak to you about Roger. Are you familiar?” Here we go.
          “I am.”
          “He especially is upset about all of this. Has he told you that he wants bone-in chicken?”
          “He is not safe to eat. He has dysphagia. He and his family opted for a feeding tube.”
          “Is that documented?”
          “Yes.”
          Mmm…it’s like I’ve done this before or something?
          I move to pull up the speech therapy notes as well as his care meeting notes, rehashing the meeting with the surveyor just as I’d practiced in my head. I’m trembling with nerves as I assure her I’ve followed each guideline as outlined by Medicare/Medicaid Code of Compliance. One slip would cost the facility a tag, a fine, possibly my job.
          I’d explained the difficulty swallowing to him, to the family, hoping they’d accept this as a normal part of aging. Of dying. Hoping they’d decline intervention. Decline a feeding tube. Let him eat his favorite foods, drink his morning coffee. Let him die.
          But they never do. They’d insisted on the tube.
          “Ok, but I don’t see anything in the notes about addressing the chicken with him?”
          “Ma’am. I can’t put bone-in chicken through a feeding tube.”
          Ma’am, he is still going to die.
          Ma’am, so are you.
          Ma’am, so am I.
          The average United States lifespan is 78.79 years.
          The unrecorded conversation had taken place in his room following the failed Resident Council meeting. It had gone something like this:
          “Roger, we just talked about this at your care meeting with your family: that speech therapy recommended a feeding tube and no oral diet. Did you understand that part of the meeting?”
          “I could give two shits what they said! You all are Nazis here. You make us miserable!”
          “You have a choice, Roger. I can approve an oral diet, if you sign off that I’ve educated you on the risks: choking, aspiration, pneumonia, and death. You always have a choice, as long as we can show you’re aware of the consequences. We couldn’t serve bone-in chicken, but we could certainly get you some roasted chicken.”
          “Hell no. I’m not signing anything! You want to just let me die? You’re nutty! I’m not goin’ anywhere. You ever hear of miracles? You can take that paper and stuff it!”
          “Ok. Then, because it is not safe for you to swallow, and you want full intervention, we also cannot serve you chicken. We’ll keep using your feeding tube. Let me know if you decide you’d like to sign off on being aware of the risks, and we can always revisit. I think that would be a very reasonable decision, if you were to reconsider, Roger. We can have another meeting. I can help you explain it to your family.” I say it as softly, gently as I can. For some dumb reason, I always think I’m going to reach them.
          “Fuck you! ”
          “Thank you, Roger.”
          So, no—that conversation isn’t documented. The silence between us swells as the surveyor stares into me. She knows she’s got me. The rumor is that her mother died in a nursing home and she’s dedicated her life’s work to avenging that very inevitable phenomenon.
          “Ok. Correct me if I’m wrong: you have documentation of his failed swallow study and care meeting with his family, but nothing on file that he was offered a choice, and declined to sign paperwork on risks and benefits of an oral diet. That will be a tag, unfortunately. He sure is upset about the chicken. Please spell your first and last name for me.”
          Her asking is a real power move, as she’s already copying from my name badge. The stud in her nostril makes me wonder if she doesn’t see through this whole thing, too? The insanity? I do not have signed documentation that the patient … declined to sign documentation.
          Despite my ineptitude, the average United States lifespan remains 78.79 years, and I spell my name out for the complaints of a ninety-two-year-old resident.

          Christina sleeps soundly, cajoled by complimentary red wine and likely some version of pain medication. My eyes stare out the window into nothing. We are surrounded by an inky blackness, thick and heavy in its absence. Absence, of immigration rules, COVID testing regulations, reality, youth. Death. This is the first time in awhile I can remember feeling present. Airplanes tend to do that. I unwrap the flight blanket under my seat, tucking it in around me to form my flight cocoon.
          The airplane lights darken to join the sky, and our upcoming scenes play across the inside of my eyelids. In seventy-two hours, we will wake exhausted from two buzzing days spent exploring Turkey’s capital. We’ll drop into a quick connecting flight, leaving city for the ancient deserts of Cappadocia. We’ll wake before the prayer chants, the burning torch of the balloon reflecting off our faces as we rise into the ocean blue of dawn. We’ll wear floating maxi dresses, padding softly back on the sand, newly warmed from the sun. We will pop champagne that sprays our air-pricked skin, and marvel at how we were able to see the curve of the earth from the balloon. We’ll be 6,500 miles from here, living. Dying.
          The too-bright voice of a stewardess drifts from the center of the plane:
          “Pasta, or chicken?” I consider asking if it’s bone-in, demanding it as the residents so earnestly do. How does the danger of choking from flight turbulence compare to seated safely on ground, but with an old throat? Who is in charge of quantifying these things? I’m amused enough to relax, fully surrendering to a snooze at the choice of chicken.
          After all, the average United States lifespan is 78.79 years.

Works Cited
1. The World Bank, 2019. https://datatopics.worldbank.org/world-development-indicators/.
2. Bruce DM, Heys SD, Eremin O. Lymphangitis carcinomatosa: a literature review. J R Coll Surg Edinb. 1996 Feb;41(1):7-13. PMID: 8930034.

Brittany Buchholz is a dietitian and writer hellbent on extolling the simple magic of being alive. She is currently a MFA student through Lindenwood University, where her focus is creative nonfiction. Her writing has been featured by Chopra Foundation and Elephant Journal (with five articles awarded as Editor’s Picks).