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Monday, December 29, 2014

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Being the ‘it’ in care isn’t easy

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An 84-year-old woman and her daughter, her primary caregiver, were in my office.

“I feel a lot better since that visit to the emergency room in the summer when they changed my medications. I haven’t had any more dizzy spells or falls,” the mother said.

The daughter concurred, and I confirmed from the discharge summary of the finding following a fall that she had blood-pressure levels that fell when she stood up and her heartbeat also slowed down. The symptoms were thought to be the result of a combination of medications she was taking for high-blood pressure, which were producing an excessive effect, leading to “postural hypotension.”

I was told that since the fall the mother was living in her daughter’s home. The mother’s apartment had suffered some water damage during a rainstorm and required repairs, but it was not yet certain if she would feel secure enough to return and live on her own, even though that was what she appeared to prefer.

Historical and testing evidence indicated that the mother suffered from mild cognitive impairment, but for most of her function and normal basic activities, she was able to care for herself. The mother repeated herself a bit, but this alone did not appear to interfere greatly with her function. She expressed herself quite clearly and understood what was happening to her.

After I asked about the mother’s current living situation and plans for the future, part of my normal assessment of patients and their living situations and support systems, the daughter asked, “Do you think my mother should move into a retirement home rather than living with me, because during the day she is alone in the house, but we have checked it all for safety and she has an emergency call system that she knows how to use?”

I looked at the patient and asked her how she felt about living in her daughter’s house, and other than musing that returning to her own home would be her preference, she said she felt comfortable living with her daughter, who had arranged the house so that she could do everything she wanted to do and be comfortable on the modified ground floor.

The daughter continued, “My sister who lives in Toronto and my brother who lives in New York feel she should be in a retirement home for safety reasons and are urging admission. She tried one that seemed very nice and suitable, but after three days she called and begged to be taken back to my house. They are now looking at others, but Mom says she really does not want to go into one.”

The patient looked at me and said, “I do not want to live in one of those places. It is either back at my own home or with my daughter.”

I explained to both the principles by which such living decisions should be made and what seemed to be the ability of the mother to participate in such decisions. “I think you all need a good discussion with someone who understands the process of personal decisions and how alternative housing arrangements should be made.”

Arrangements were made for a family meeting with a social worker. The mother seemed very pleased that her wishes were being listened to and respected – that step and process is key to any such discussions. Being the “it” in the middle of family discord is not always easy.

 Dr. Michael Gordon is medical program director of palliative care at Baycrest. His latest book is Late-Stage Dementia, Promoting Comfort, Compassion and Care. His previous book, Moments that Matter: Cases in Ethical Eldercare, follows his memoir, Brooklyn Beginnings: A Geriatrician’s Odyssey. All can be researched at his website: http://www.drmichaelgordon.com.

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