As you are now, so once was I; Prepare for death and follow me. The novel's advisory epigram prepares readers for the realities of aging and death which affect both narrator and reader. Following surgery, Caro Spencer is delivered to Twin Elms, a nursing home in a rural New England setting. While this intelligent woman requires only short-term care, she is deposited, permanently, in an understaffed, sub-standard care facility by relatives unwilling to add her minor but time-consuming difficulties to their own.

It is not a pretty setting. The staff is overworked and demeaning, especially to the new resident who is well-educated and accustomed to better circumstances. The nursing home routine is careless of individual differences and needs, and set up to strip away autonomy and dignity through petty and cruel indignations.

Caro is able to survive by keeping a secret diary for observations, reflections, and interpretations; ultimately, this alone sustains her. While the voice is that of an elderly woman (as we are now), the journal is for us, those still able to manage their lives, but unable to predict or control end-of-life events.