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At some point in life, you can’t live on your own anymore. We don’t like thinking about it, but after retirement age, about half of us eventually move into a nursing home, usually around age 80. It remains your most likely final address outside of a hospital.

To the extent that there is much public discussion about this phase of life, it’s about getting more control over our deaths (with living wills and the like). But we don’t much talk about getting more control over our lives in such places. It’s as if we’ve given up on the idea. And that’s a problem.

This week, I visited a woman who just moved into a nursing home. She is 89 years old with 1)congestive heart failure, disabling arthritis, and after a series of falls, little choice but to leave her 2)condominium. Usually, it’s the children who push for a change, but in this case, she was the one who did. ‘‘I fell twice in one week, and I told my daughter I don’t 3)belong at home anymore,’’ she said.

She moved in a month ago. She picked the 4)facility herself. It has excellent5)ratings, friendly staff, and her daughter lives nearby. She’s glad to be in a safe place―if there’s anything a decent nursing home is built for, it is safety. But she is struggling.

The trouble is―and it’s a possibility we’ve mostly ignored for the very old―she expects more from life than safety. ‘‘I know I can’t do what I used to,’’ she said, ‘‘but this feels like a hospital, not a home.’’ And that is in fact the near-universal reality.

Nursing home priorities are matters like avoiding 6)bedsores and maintaining weight―important goals, but they are means, not 7)ends. She left an 8)airy apartment she furnished herself for a small 9)beige hospital-like room with a stranger for a roommate. Her belongings were 10)stripped down to what she could fit into the one cupboard and shelf they gave her. Basic matters, like when she goes to bed, wakes up, dresses, and eats were put under the rigid schedule of institutional life. Her main activities have become 11)bingo, movies, and other forms of group entertainment. Is it any wonder most people dread nursing homes?

The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. She’s not alone. Surveys of nursing home residents reveal chronic boredom, loneliness, and lack of meaning―results not fundamentally different from prisoners, actually.

Certainly, nursing homes have come a long way from the 12)firetrap warehouses they used to be. But it seems we’ve settled on a belief that a life of worth and 13)engagement is not possible once you lose independence.

There has been, however, a small band of 14)renegades who disagree. They’ve created alternatives with names like the Green House Project, the Pioneer Network, and the Eden Alternative―all aiming to replace institutions for the disabled elderly with genuine homes. Bill Thomas, for example, is a 15)geriatrician who calls himself a ‘‘nursing home abolitionist’’ and built the first Green Houses in 16)Tupelo, 17)Miss. These are houses for no more than 10 residents, equipped with a kitchen and living room at its center, not a nurse’s station, and personal furnishings. The bedrooms are private. Residents help one another with cooking and other work as they are able. Staff members provide not just nursing care but also mentoring for engaging in daily life, even for 18)Alzheimer’s patients. And the homes meet all federal safety guidelines and work within state-19)reimbursement levels.

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They have been a great success. Dr. Thomas is now building Green Houses in every state in the country with funds from 20)the Robert Wood Johnson Foundation. Such experiments, however, represent only a tiny fraction of the 18,000 nursing homes nationwide.

‘‘The No. 1 problem I see,’’ Dr. Thomas told me, ‘‘is that people believe what we have in old age is as good as we can expect.’’ As a result, families don’t press nursing homes with hard questions like, ‘‘How do you plan to change in the next year?’’ But we should, if we want to hope for something more than safety in our old age.

‘‘This is my 21)last hurrah,’’ the woman I met said. ‘‘This room is where I’ll die. But it won’t be anytime soon.’’ And indeed, physically she’s done well. All she needs now is a life worth living for.

人生到了一定时候,你就再也不能照顾自己了。我们不愿去想这些事情,但是过了退休年龄以后,通常在80岁左右,我们中大约一半的人最终会搬进疗养院。而那个地方将会是你除了医院之外的最有可能的命终归宿。

提到大众对这一人生阶段的讨论,大多围绕着应如何更好地应对掌控死亡这一问题(比如说生前立遗嘱之类的)。但我们很少谈论到怎样更好地掌控自己在疗养院里的生活。好像我们已经完全不去想了。而这正是问题所在。

这周,我拜访了一位女士,她刚刚住进了一家疗养院。老人家已经89岁了,并且有充血性心力衰竭和导致她行动不便的关节炎,在连续跌倒过几次之后,她别无选择,只能离开之前的公寓大楼住到疗养院。通常状况下,都是孩子们把老人送去疗养院,但是这位老奶奶的情况却是她自己决定住进疗养院。“一周之内我摔倒了两次,我告诉女儿我不再适合住在家里了。”她说。

她是一个月前住进疗养院的。这家疗养院是她自己挑的,其声誉好,工作人员友善,而且女儿就住在那附近。她很高兴 自己能待在一个安全的地方――如果说一家像样的疗养院是为了某个目的而建造的话,那就是安全。不过,老人家适应起来还是挣扎了一番的。

问题是――这也可能是对老人我们通常会忽略的地方――她期望从生活中得到更多而不只是安全感。“我知道我不能做我之前做的事情了,”她说,“但这里让人感觉像个医院,而不是家。”事实上,这几乎是很普遍的情况。

疗养院摆在首位的大事无非是让老人家避免褥疮和维持体重等――都是些重要指标,但这些只是途径而非目的。老人家离开自己装饰布置,通风透气的公寓,来到一间米色调、像医院病房一样的小房间,还要和一个陌生人做室友。她只能携带一些有限的生活用品,而且是要能够放进疗养院提供给她的一个壁橱和架子里的。一些基本的生活问题,比如睡觉、起床、穿衣和吃饭时间都被严格制度化,得按章进行。她的主要活动变成了玩宾果游戏、看电影和其他形式的群体娱乐。这样的疗养院生活怎么会不令大多数人心生恐惧呢?

老人家告诉我,她最怀念的是她的友谊、隐私和她每一天的目标计划。她并不是一个特例。据调查显示,居住在疗养院里的老人们会长期感到厌倦无聊、孤独寂寞和缺乏生活目标――实际上,这些调查结果显示的与囚犯们的感受没什么根本区别。

当然,疗养院从过去那种充满火灾隐患的仓库式建筑发展到今天这种状况已经是很大的一个转变了。但我们似乎早就笃定了一种观念――一旦生活不能自理,想过有价值有保证的生活就是不可能的了。

不过,有一小群“叛逆者”不同意上述观点。他们提出了诸如“绿园计划”、“先锋网络”和“伊甸园他选”等替代 物――所有这些计划都志在用真正的老人之家来取代那些向不能生活自理的老人提供帮助的机构。例如,老年医学专家比尔・托马斯,自称是“疗养院废除主义者”,就在美国密西西比州的图珀洛市建立了第一所“绿园”。这些房子里的住客不超过10人,房内配备了厨房,房子中央是客厅而不是看护工作台,还配备了私人家具。卧室是私人的。住客互相帮忙一起烹饪以及分担其他一些他们能做的事情。看护人员不仅要提供看护,还要指导他们如何过好日常生活,甚至包括指导患早老性痴呆病的住客。这些房间全都符合联邦政府的安全指引,而且其费用标准也没超出国家福利资助范围。

他们取得了巨大的成功。依靠罗伯特・伍德・约翰逊基金会的资金支持,托马斯医生现在正在美国的各个州建立“绿园”。然而,类似“绿园”这样的试点在全国范围内的18000所疗养院中所占的比例微乎其微。

“我觉得,最大的问题是大家都觉得现在提供给老人的服务已经不错了。” 托马斯医生告诉我说。结果,人们就不会向疗养院施压,提出诸如“你们打算下一年做些什么改变?”之类的难题。但是如果我们想要期待自己年老时可以得到一些除了安全感之外的东西,那我们就应当提出那些问题。

“这是我最后的努力,”我探访的老奶奶说,“这个房间将是我离开人世的地方。但是这还得有一段很长的时间。”确实,她的身体状况还很好。现在她所需要的是一种过得有意思有盼头的生活。

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