Letting Mom and Dad Live on Their Own Terms

Author: Janice Van Dyck

Millions of us went home for the holidays. Well, not "home" exactly. In reality, millions of us left home, and went back for the holidays. Back to who we used to be, back to where we came from, and in some cases, back in time. Like salmon up the river, we inexplicably navigated back to the people of our birth. Our parents.
Have you ever made the trip thinking, what if this is the last time? Parents age, especially when we're not looking, and most especially when we live far away from them. Periodic visits sharpen our senses. All of a sudden, we may be witnessing our parents in steep decline, heading toward the exit ramp, and it raises all kinds of questions.
When will it be time for assisted living? Should Mom still be driving? Are they taking their pills? Is Dad's memory actually shot?
These realizations can be tough, especially if your parents have been role models of determination and resourcefulness. Dealing with normal age-related decline can cause dissention amongst siblings, too, because each has a different relationship with Mom and Dad. For example, in my family, my sister lives closest to our father, and has regular visits with him. My brother and I live in different corners of the country and our main contact with Dad is by e-mail and telephone. Who is in the best position to judge how he's doing? As he approaches the 80-year mark, who has got the best perspective on his health?
This same conversation came up a few days ago in my book club, and again with friends at dinner last night. It seems that everyone of a certain age with living parents has the same questions. There are no easy answers. But I offer these three issues at the root of the debate:
Whose life is it anyway? We live our lives free to make our own mistakes, to put ourselves at risk and determine our own destinies. Why should this change just because we're old?
In our culture, roles often reverse: At some point adult children seem to think they need to parent their parents. This is fine if a parent asks for help, but often elderly parents are resentful because their middle-aged kids keep bossing them around. Their final years are full of conflict and humiliation because of well-meaning -- but strong-willed -- children, intent on removing the "risks" of living. So what if Dad's floors are dirty or your parents don't take their medicine and are going to get sick? If it's their choice, then perhaps you need to reconcile yourself to the fact they're not living their lives your way. And that's ok. After all, since anywhere from your teen years forward, they had to adjust that you weren't living your life their way.
Are your parents capable of clear thinking and reasonable risk assessment? Again, remember that at one time (or perhaps several times), they doubted your ability to make decisions. The point here is whether or not there's an actual, treatable medical/psychological impairment that would prevent your parent from rational thinking and action. And unless you're a doctor, you really can't make this determination on your own.
Consider getting an expert opinion before you take your parents' checkbook away. When they want to blow money at the casino or turn the heat down too low or mow the lawn themselves, just remember that even though it isn't what you want for them, that doesn't mean they shouldn't be allowed to do it. That being said, a parent who is unable to fend for him or herself because of a disability obviously needs help. But when it comes to your parent's livelihood, be careful to distinguish between fact and opinion.
Are your parents putting other people at risk? This again, is a matter of degree. Take driving, for example: We all put others at risk each time we get behind the wheel of a car. Senior citizens represent about 15 percent of all drivers, and they tend to get in more accidents due to age-related skill decline. But driving is risky anyway, and younger people can be even worse drivers than someone's 82-year old father driving 40 mph on the freeway.
So when calculating the risk factor, be realistic. If you worry about your parent causing a fire, it is obviously more dangerous if they live in multi-unit complex than a single home.
If you're struggling with how much autonomy and freedom your parents should have as they age, remember that someday, someone will be making the same decisions for you. Show your kids how you want to be handled in your old age by setting an example with your own parents. I don't know about you, but as long as I'm not hurting other people or actually incapable of making my own decisions, I want to be able to live with the consequences of my own actions, regardless of how old I am.
And you know what? Maybe that's a concept we're losing in our society, the idea of consequences. We can't protect our kids from getting hurt in life by putting a bicycle helmet on them in the stroller (which I actually saw the other day). Nor can we protect our parents from dying by taking away their dignity, freedom and choice. When we're born, the only guarantee is that someday we're going to die. That's the risk of living.
Since losing our parents is inevitable, why not let them do it on their own terms? I know of a man, now 94, who bought into a senior living community in his 80's. He hated it and moved out despite the protests of his family. I applaud his courage! What's the worst thing that could happen? He might die alone, on his own terms, looking around at his own belongings, satisfied that his life was well lived.
His only regret might be that his children didn't understand.

http://www.huffingtonpost.com/janice-van-dyck/how-storytelling-can-exte_b_805502.html

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Who Thrives After Surgery?

By PAULA SPAN
Martin A. Makary, a surgeon and public health researcher at Johns Hopkins Hospital in Baltimore, had a long talk with a patient last week. The man had a tumor in his pancreas that was probably benign but might not be. Should Dr. Makary remove it? Or should the man have regular scans to see whether it grew?
"If you're 25, the decision is easy — get rid of that risk," Dr. Makary told me afterward. But this patient was 89.
Let's pause for a moment to consider the changing surgical landscape. When Dr. Makary was in training, he recalled, surgeons were just starting to offer elective procedures to patients in their 70s. Now, with better techniques, safer anesthesia and, of course, more old people — half of all operations in the United States are performed on those over age 65.
"It's become acceptable to do major procedures on very old patients," he said. "We routinely do elective surgery on people in their 80s and 90s."
That doesn't mean it's always a good idea, or that it's easy to calculate the costs and benefits. How very old patients respond to surgery has proved unpredictable. "There are some people you worry won't do well, and then they fly," Dr. Makary said. "And some people you are confident will do well have a cascade of symptoms that lead to their demise or permanent disability — and everybody is shocked."
Surgeons eyeball their patients all the time to try to evaluate whether they can recover well from the stress of an operation, but it's an inexact science. "You can be thrown off by hair or teeth or wrinkles, things that don't have much to do with physiologic reserve," Dr. Makary said.
The usual tests surgeons use to try to predict how older patients will fare are crude, Dr. Makary added, mostly based on cardiovascular strength. And standard estimates of mortality and length of hospitalization for specific operations are all but useless for patients who might be 30 or 40 years older than the norm.
But thanks to a rather elegant piece of research by a Johns Hopkins team, recently published in The Journal of the American College of Surgeons, surgeons can give more informative answers when elderly patients in this situation, or their families, wonder what to do.
For years, the geriatrician and gerontologist Linda P. Fried, now dean of the Mailman School of Public Health at Columbia University, has been talking and writing about frailty. We laypeople tend to use the word imprecisely to allude to fragility or vulnerability in old people, but for physicians and researchers, frailty is a specific medical syndrome with measurable criteria.
They look for a series of declines that include weight loss (specifically, an unintentional loss of 10 pounds or more in the past year), a weaker grip, exhaustion and lack of physical activity, and a slower gait. The assessment takes perhaps 15 minutes to conduct in an office. Then the doctors assign a score: 0 to 1 for those who aren't frail, 2 to 3 for the intermediately frail.
Patients who score 4 to 5 are frail. "They tend to have much less reserve, a decreased ability to bounce back" from physiological stress, said Dr. Fried, who previously taught at Johns Hopkins.
Might frailty scores be better at predicting how patients fare after surgery than the existing methods? For a year, Dr. Makary, Dr. Fried and their colleagues at Johns Hopkins tracked nearly 600 patients over age 65 who had elective surgery in that hospital – from minor gallbladder removal to joint replacement and major abdominal surgery. All lived independently.
The researchers assessed patients' frailty before their operations: slightly more than 10 percent were adjudged frail (average age 76.3), and more than 58 percent weren't frail at all (average age 71.3). The remainder were classified as intermediately frail.
"The data are quite persuasive," Dr. Fried said. "People who are frail before surgery are at higher risk for poor outcomes afterwards." This is the way careful researchers talk; they say results are "persuasive."
A layperson like, say, me would say: Yow. The frailty index did a superior job of predicting how seniors will do after surgery, and just look at the extent of the differences.
Those who were intermediately frail faced twice the odds of complications after surgery, compared to patients who were not frail, according to the study; frail patients had more than two and a half times the complication rate. Hospital stays were 44 percent to 53 percent longer for those intermediately frail, and 65 percent to 89 percent longer for the frail.
And after operation, the odds of a patient being discharged to a nursing home or to assisted living, instead of her own home, rose in proportion to her frailty. The intermediately frail were more than three times as likely to have to enter such a facility, compared with those who were not frail. The frail were 20 times (not a typo) as likely to go to a nursing home or assisted living — from which they may or may not have emerged.
"If the risks are likely to be higher, it changes the equation as to whether the surgery has benefit," Dr. Fried said.
That 89-year-old patient, for example, turned out to be intermediately frail when Dr. Makary evaluated him using the frailty index. "I thought he was stronger," he acknowledged. After considerable discussion, doctor and patient agreed not to remove the tumor, but to track it with annual scans.
Surgeons at Johns Hopkins have widely adopted the index to help make such pre-op decisions, and Dr. Makary says he has heard from surgeons at about a dozen other major medical centers who are also using it. In some cases, patients may decline surgery. In many, they and their families will have a more realistic idea of how long recovery may take and how much help they will need.
This is a question, Dr. Makary suggested, that older patients and their families ought to routinely ask their surgeons in fairly blunt terms: You want to operate on my father? You think he's too old for surgery? What's his frailty score?

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http://newoldage.blogs.nytimes.com/2010/12/28/who-thrives-after-surgery/?partner=rss&emc=rss

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