I really enjoy elder care in Family Medicine. Mostly. Even some of the very difficult or very complicated people.
One thing I would try to figure out is what is the person’s goal? This can be quite funny at times.
“Can we talk about what you would want if you got really sick? If you were too sick to talk to us?”
“I don’t want to talk about death.” Ok, this person is in their 90s.
“That is fine, but if we don’t talk about it, your daughter and I have to guess what you want. And we tend to do more when we don’t know.”
That person glares at me. “Oh, all right.”
Sometimes a person says, “I don’t want to die of cancer.”
It turns out that this is an opening. “Ok, what DO you want to die of?”
“I don’t want to die!”
“Well, me either, but I can’t fix that. There are at least three “ideal” deaths that the Veterans Administration talks to people about. Maybe we could go over them. You could put your request in with your higher power.” I have written about the three here: https://drkottaway.com/2023/10/06/an-ideal-death/. The “Hallmark” or hospice death, sudden death and fight it all the way.
But, other than not dying, what is the goal? To stay in one’s home? To move to a retirement organization that has a nursing home and care until death? Home care insurance to stay home? I do have people imply that they will go into the woods or crash their car or something if they get very sick, but not very often. They are usually aware that I have to respond to any suicide threat. How much care do they want? People often say, “I wouldn’t want to be disabled,” but it turns out that life is often worth living even when very challenging. Most people want to be treated for cancer, for heart disease, for congestive heart failure, to go on.
Sometimes death comes from a cumulative load of chronic problems. We had a gentleman in his 80s in the hospital ICU many years ago. He had pneumonia, congestive heart failure and bad kidneys as well as a host of other problems. I sat down with him. “We are treating you, but when we give you enough medicine to help you breathe, your kidneys are getting worse. This is a small rural hospital. I could transfer you to the Seattle hospital, 2 hours away. You would have a cardiologist, a kidney doctor, a lung doctor. Here you just have me and the nurses. Either way, I do not know if you will live through this. What do you want to do?”
He chose to stay. “My family can visit me here.” His family was visiting daily. “I do not want a breathing tube. I do not want dialysis. If my kidneys go, let me go.” We discussed this with the family.
Four days later it was clear that without dialysis, he was dying. Dialysis might have slowed it, but he may still have died. He was no longer waking up. We withdrew the antibiotics and removed most of the monitoring and switched him to hospice. His family continued to visit and he died a few days later.
He did die in the hospital, and yes, we used some machines up until care was withdrawn, but this still seems like he got to make choices and his family understood. It can be much harder with memory loss when the person really can’t make choices any more.
He was complicated. To keep him breathing well without a machine, we had to give him diuretics, that were eventually too much for his kidneys. A bad heart, lungs with emphysema and pneumonia, and bad kidneys. Sometimes the liver is not working either, and then what is there left to work with? Nearly all drugs are broken down by either the liver or kidneys. Simethicone is not absorbed, so that’s the exception.
Sometimes people get along until too many things accumulate and then they end up in the hospital and on multiple new medicines. It can be very confusing. Regular maintenance is a good idea.
Sometimes the family wants something different from the patient. Or there is an elder parent and three adult children, who all disagree. My job is advocate for the patient. But this is Family Medicine, so I have a responsibility to the patient but also to the family. The person, the family, the community, how is it all fitting together? Sometimes functional, sometimes not.
I had one person who called me when he had been flown to a Seattle hospital. “I have to get home.” he says, “Can you release me? I have to take care of my wife!” I panicked for a moment. “Is your wife bedridden? Where is she? Why are you in the hospital?” She was not bedridden and she was fine. He was being more and more behaviorally squirrelly. He could no longer drive, but drove anyhow. His wife disabled the car, because he would disappear. I sent him to a neurologist for memory testing. The neurologist said, “Hmmm.” and sent him for neuropsych testing. The neuropsych report said dryly that his memory was fine, but he had certain long standing behaviors related to past heavy alcohol use. Oh. He was quite proud of not drinking and going to AA, but he also triangulated with his family and me. I sat him down and said, “Ok, I am not going to talk to a different one of your five children every time you see me in the clinic, because you’ve said, “Don’t tell mom I called you.” Pick ONE person for me to talk to and now you have to have a family member with you when you come to clinic.” He grinned and chose his wife. He had certainly fooled me about his memory, because he blamed his behavior on his memory. The neurologist was not quite fooled. The family calmed down and he did not drive any more, thank goodness. He was not an easy patient, but he was entertaining and educational too. And I felt that I had helped both him and the family.
Sometimes families fight. Sometimes a dysfunctional family will get way worse when someone is sick or dies. Sometimes families go on fighting. Other families are so kind and so good to each other and their elders. Every family is different.
For the Ragtag Daily Prompt: concentration.
KO Rural Mad As Hell Blog 
I can’t have what I want because it’s against the law. That so pisses me off.
A few points:
1.) Those who glibly talk about a final jaunt into the woods seem to be willingly blind that end times can sneak up on you bit by bit. until your choices are limited.
2.) Some of my favorite informants when I did fieldwork were seniors. A number of them expressed that they were glad not to live for ever, and seemed willing to accept it because they’d outlived so many family and friends that they found themselves in a world they no longer recognized.
3.) Not all “Sudden” death is one and done in a second. There can be some significant suffering along the way.
Yes to all three.
It is difficult, especially with things like brain cancer, where it takes away that person to their loved ones before it happens. I think cancer is one of the diseases, which scares me the most because I have had many close family members die from it. Mostly because they smoked, but some didn’t. I think I am getting to an age where I do think about it more, but I want to live my best life. I want to be there for my children, brother and husband. I also want no regrets.
Yes, my mother died at 61 of ovarian and sister at 49 of breast cancer. One of my elder patients said that memory had taken her husband. “HE’S gone. He just left his BODY.” She had to put him in care because he outweighed her by 50 pounds and was a wanderer: he would disappear and be found a mile away.
That is sad, and a difficult choice to make. It was my sister that affected me the most. She was only seventy, and had pancreatic cancer. My mother-in-law was in the middle stages of dementure, but thankfully never forgot who her family were.
I am sorry.
π
You and I have discussed death here before so I won’t repeat myself (I hope). After years working in a hospital and seeing all kinds of deaths, I wrote a detailed advance directive before my first cross country bike trip, just in case something happened on the road. I discussed it with my wife and kids. Six years later, my wife still won’t write an advance directive. She doesn’t want to think about it. Or maybe she just trusts my judgment; but it might not be my decision to make (as she could outlive me) and she hasn’t talked with the kids about it.
Do the choices I made six years ago still apply? Yes. I review it every now and then to be sure I still agree with my younger self. Might I panic and change my mind when death is near? Sure. I can know what I think when death is still abstract but I can’t know what I’ll think if it’s staring me in the face. We can always change our minds if still thinking clearly. Folks don’t always realize that the written document is in case they can’t make decisions at the time; not an ironclad replacement for discussion at the time. It represents our best thinking when we have time to think about it and can be the basis for that discussion.
One of my favorite patients (I hope I haven’t written this here before) had Crohn’s Disease. The first time we met, he told me he’d been given a few years to live at age 18. He was now around 80. He grabbed me by the lapels, pulled me close, and said, “Buddy, your job is to make sure I don’t get no fuckin’ colostomy.” I told him I didn’t have the power to decide that, but I’d make his wishes known and he should too. He died several years later, colon intact.
I’ve read dozens of obits about people who “fought a courageous battle with cancer”. I told my daughter I want them to write that I went out kicking and screaming, crying like a baby and shouting, “Not me! take him! I’m too young to die!” Luckily we share a sense of humor and they knew what I meant.
Heh, I’m with you. I hear people say we should die “with grace”. Who the hell is grace? I think that people should be allowed to die with whatever emotion comes up: afraid, curious, angry, sad, surprised, peaceful, grumpy, whatever. Usually when someone is saying we should die with grace they mean someone other than themselves. “Go out without suffering and don’t bother us!” My mother said she’d take to her bed when she got old. “I’ll whack you with my cane when I’m in a bad mood.” This was partly in reaction to her mother, who was so worried that she’d bother us that she melted a lamp by putting a blanket over it when she was sharing my room for a night. My sister told my mom we’d leave her in that bed alone. I miss them both, sigh.
Why die with grace if we can get Grace to die in our place? ;)
I read that Aldous Huxley died while under the influence of LSD – not that LSD killed him, but that he asked his wife to administer it to him as he was dying. I thought about that and realized I only get to do it once, so maybe being under the influence of dying is enough. As Memphis Slim (at least in Mother Earth’s version of his song) said of death, “There’s no one who’s gone over there and come back to talk to me about it yet.”
The emperor Vespasian supposedly quipped as he died, βOh dear, I think Iβm becoming a god!β Well if you’re going to go you might as well go with crass, I mean class.
My grandmother’s comment was, “Look, Mac, I’m dying.” Mac was my father. He replied, “I’m looking.”
Right to the point!
I love it!