LAST WORD

Patient vs family: We have to play a role

By Donald A. Kushner, MD

After speaking with Mr. W for 45 minutes about everything from his health, to his philosophy of life, to his contentment living at home by himself, I felt I had met all this elderly patient's needs. Finally, a model patient encounter just like I was taught, including physical and psychosocial issues. I had bonded with my 80-year-old patient, and we both left the exam room satisfied.

Before I could finish congratulating myself, however, my nurse informed me that Mr. W's out-of-town daughter was on the phone. "Whatever you do," she implored me, "tell my father he must move into a nursing home." After I picked my jaw up from the floor, I prepared to address the uphill battle the three of us will face.

As physicians, it's our job to advocate for our patients. But what happens when the conflict is with their adult children? As an internist with a significant elder population, I've seen many such conflicts. For the children, safety is the priority; for the elderly patient, it's quality of life.

Each side looks to us to support their point of view. Our goal should be to provide that support for the entire family, while fostering the safety, health, and well being of our patient.

Take a frequent conflict: driving. The children feel it's unsafe for their parent to drive, and they offer to take him anywhere he wants to go. For the parent, his independence is paramount. He may be grateful for his children's attention and concern, but he's willing to sacrifice his safety to prevent burdening them.

The first thing we doctors must do is facilitate communication between the members of the family. Both parent and child must be made aware of the other's feelings. Once that happens, it may be possible to reach a compromise. In the driving scenario, perhaps the parent could use buses, cabs, or the town's elder transportation service. That would allow him to have his independence but would assure the children that he'll be safe.

Another major area of conflict, as in the case of Mr. W: living arrangements. Should the parent give up her home and move in with a child? The children may view the opportunity to live with them as a tremendous gift, but the parent often finds it unpalatable. (More than one elderly patient has told me she dreads the prospect of living with teenagers!) Or should the parent move to an assisted living facility, which would provide a level of safety as well as daily activities? Both those options would make the child feel better. But for an elderly person, a change of environment may sever her link to the past, something that gives significance to her life.

Again, it's our job to help each party truly understand the other's point of view. With this understanding, they can often achieve a compromise, such as a Lifeline button or home care.

Above all, we must understand—and help our patients' grown children understand—the change in perception as we age. Children often think that their parent isn't functioning as well as he should because of a medical problem. They don't realize that as we get older, our desire for activity may lessen. So sometimes a parent's "withdrawal" is simply the natural course of aging.

For younger people, lives are measured by the next life event. For the older person, though, it's as if they'd just spent a month at Disney World. They've ridden all the rides, seen all they care to see, and now are simply content to go home. It's our responsibility to help their children understand and accept this process.

That's advocating for our patients.

The author is an internist in Pittsburgh.

 

Donald Kushner. Last Word: Patient vs family: We have to play a role. Medical Economics Jul. 25, 2003;80:88.