Tag Archives: love

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Elder Care: Goals

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.

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room

In my room, where is that?
In my room, the room in my head, there is home
and wilderness, unexplored and unending, never tame.
All the wild places I have been, or seen, or heard of
or imagine. It’s a wonder that I can speak at all
words in the daily day, after wandering the wilds.
Why does anyone ever come back?

Why does anyone ever come back?

Except to explore other rooms and add them to ours.
I listen to the Brahams Requiem, a painting in orchestra and voice,
of his room, his wilderness, his despair and joy.
I am glad to come back for this and others like him.

That is why anyone comes back.

For the Ragtag Daily Prompt: in my room.

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Envy

I am supposed to write about envy
but what I am feeling is grief
I walked five miles yesterday
and it was fun, talking, a group
but then a nap from 2 to 5, three hours
and to bed at seven pm and up at five
so 13 hours sleep in response to exercise

It is time to downsize what I think I can do
I still have my mind, but the energy is halved
I can’t work full time as a physician
and I am not sure I can work half time
Do I try it? The risk that I crash again?
Pneumonia and death? Or do I curl into the grief
and find something else to do.

Even the thought makes me tired.

Not envy of other doctors, oh, maybe a little
but the truth is, my survival to date is something
of a miracle. Babies with mothers with active tuberculosis
usually die very quickly, infected, overshelmed.
My mother kindly coughed blood so the doctors knew
before I was born, from the protection of the womb
to the protection of the family, away from my mother.
She is dead, my father is dead, my sister is dead
so even if I cannot work half time
it’s still miraculous to be here at all.

I hope that each and every one of you
feels the miracle of not being dead and gone
some days. And that you do not envy
your dead.

For the Ragtag Daily Prompt: envy.

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Give love

Martin Luther King’s birthday and a federal holiday. To be blunt, we need to stop killing each other and hating each other. And an awful lot of hate is based on fear: fear of others, fear of losing money or status or standing.

Give love.

For the Ragtag Daily Prompt: blunt.

The photograph is from September 2022, from my road trip with my friend Maline Robinson. She is second from the right in the photograph. We visited her in-laws in Beloit, Wisconsin on a road trip, going to visit her old friends and family. Her husband George Harrell had died of lung cancer in 2015. Maline died in February 2023.

I am the short one, in the skirt.

Let peace and love spread over the world, justice and an end to discrimination.

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1932 Letter

My cousins sent me a packet of letters. Some are from my mother to her mother, but this one is from… well, see if you can guess.

Dear Mother and Father,

We got in the car and Grandfather and me sat in front and Grandmother sat in back. Grandmother said, “Do you want your window closed?” and I said, “No.” Then, in a few minutes after that I said, “I am getting kind of chilly.” Then in a few minutes after that I tumbled over the back of the seat into the back seat. Then I shot my pistol out the window and tried shutting it again but it wouldn’t go. Then I waited awhile and then I shot off my pistol again and it worked. Then I shot off my pistol again in a few minutes after that but somehow it didn’t work. And then after awhile it started raining.

Then we got home. After a little while Eva May came over. Then after awhile Jimmie came. Jimmie brought over his gun with him. He had a long gun.

After supper I took my sparklers over to Jimmy’s and Eva May’s house. They invited me over before supper and then I started lighting my sparklers. I lit one after another and in a few minutes I said, “I’ll go over and get my pistol,” so I did.Then I went back for awhile and then I came home and stayed and we had the rest of my sparklers in the house. And then we all went to bed pretty early.

This is postmarked July 6, 1932 Decorah, Iowa. It cost .03 cents in stamps to mail. It was sent to Mrs. Temple Burling, 3434 Arden Ave, Hollywood, Illinois. The handwriting is quite beautiful. The letter is signed “Bobby” in quite different handwriting. The letter was sent from “Bobby” — Robbins Burling, age 6, as the narrator, with one of his grandparents transcribing to his mother (my grandmother) Mrs. Temple Burling (Katherine White Burling). I think it is a charming letter and so like a kid, with the repeats: “and then in awhile”. I am going to send it to “Bobby’s” grandson, who now has a child of his own. Here is the rest:

In the morning I got up and got dressed. Before I got up I was real quiet because I thought they were asleep because they were so quiet and they thought I was asleep because I was so quiet. Then finally they came past the door and when I knew – it they were awake – and they knew it – I was awake. And then I got up and got dressed.

Then after breakfast Grandmother and me went out and weeded. In a few minutes I said, “I’ll get the hay off the lawn for you.” so I did. I told her if she thought it was worth a penny and Grandma said, “Yes.” And then I said, “Do you think it’s worth any more than a penny?” and Grandma said “Yes.” In a few minutes we came in and she gave me a cent.

I left the penny in my hand and Jimmie came over and called me and we decided that we would make giant fingers and then as we were making giant fingers we decided we would make funny masks but we didn’t. We decided to make Chinamen’s hats but we didn’t.

Jimmie wore his hat in a funny pointed way and I wore mine with a round hole in the middle and kind of crooked too. And we went out to scare the girls and at first we didn’t scare girls but we scared Jimmie’s mother and we didn’t scare the girls after all. He went out to scare a man and he told me he’d be back and I got an idea while he was gone but he didn’t appear.

And then we went out and did some errands – got some peanut butter and then went to the library to see if they had any Dr. Doolittle books and they did. At first they asked if we’d read Dr. Doolittle at the Circus and I said, “I have.” and they put that back and looked some more and found another and asked me about that and it was called Dr. Doolittle and the Movie. Then at night Grandma read me some. We read part of it while I was in bed and then I started talking to Sixen and fell asleep finally and work up next morning. Then we had breakfast and I raked some more and I got another penny.

Bobby

For the Ragtag Daily Prompt: letter.