Nasty, Brutish & Long: Adventures in Old Age and the World of Eldercare

Ira Rosofsky. Nasty, Brutish & Long: Adventures in Old Age and the World of Eldercare. Avery. New York, N.Y. 2009. 214 pages.

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If our bodies or minds fail us at the end of our lives, we're likely to end up in a nursing home. What is life like in these institutions and what does the experience tell us about our society's way of managing the ravages of old age? In this important and engaging book, a psychologist with years of experience treating residents of various nursing homes reveals the bureaucratic, medicalized and sometimes heartless world behind the cosmetic facades of places with names like "Pleasant Manor," and reflects on how care at the end of life could be made more humane.

Ira Rosofsky is a congenial and wryly humorous guide as he brings readers into the rooms of nursing home residents (their identities well concealed) and contemplates the meaning of what he sees and hears. Along the way, he interweaves his own encounters with end-of-life care brought on by the protracted decline of his father. We learn the differences between posh and scruffy nursing homes, and how in the end they are essentially the same cages, gilded or not. We are initiated into the mysteries of the patient chart and other paperwork required by Medicare and Medicaid. We gain an insider's view of the various Medicare-reimbursable professionals who minister to the aged and infirm in these institutions.

Rosofsky is not a didactic writer who hits readers over the head with his conclusions, but he raises a great many crucial questions in his physical and cerebral ramblings. He wonders why the final home for so many of us needs to look like a hospital, with most residents afforded only a curtain for privacy. He peers behind the veil of claims for the effectiveness of Alzheimer's drugs like Aricept and Namenda and finds them wanting. "These drugs put cut flowers in water -- prolonging the agony," he concludes, while noting that narcotics for pain medication are often scandalously underused. In the final chapter -- aptly titled "The Final Chapter" -- Rosofsky ruminates on the ethics of euthanasia and our willingness to spend the equivalent of an Ivy League education to prolong a doomed life for a few months.

A philosophy major in college, Rosofsky borrows his title from Thomas Hobbes, and within the book's pages he finds occasion to casually reference Hegel, Kant, Locke, and William James, among others. Although it's a lively read, in the end his account of life among the elderly is a deeply philosophical work that forces us to rethink the meaning of, and our response to, physical decline and mortality.