Jane Moffett is a doctorate-level clinical social worker with advanced certifications in trauma. She works in New York City as a psychotherapist in private practice and is the Clinical Director for the Integrative Trauma Clinic at the National Institute for the Psychotherapies. She has long had an interest in the intersection of psychotherapy and spirituality and in mind-body practices. We are calling on her 28 years’ experience as a psychotherapist to speak to women in the second half of life who hope to find meaning in adversity and to develop practices for serenity. —Ed.

 

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In Being Mortal: Medicine and What Matters in the End, Dr. Atul Gawande, a surgeon and Harvard medical professor, draws us artfully into a discussion about aging, nursing homes, and choice points in terminal illness through personal accounts of his grandfather, father, and mother-in-law’s final years. His grandfather, Sitaram Gawande, lived in a small village in India. When Mr. Gawande Sr. was unable to manage living independently, his family stepped in to ensure that his life would change as little as possible. Cared for by a multigenerational team, his grandfather lived the life he wanted until age 110. Atul Gawande’s own father’s final years were spent much the same way; he died of a terminal illness in his own home.

But the Gawande family story is no longer a common one. The author points out that with improvements in health, nutrition, and sanitation, people are living longer. At the same time as the aging population is growing, large families are no longer the norm, and significant strains are being placed on younger family members who care for the frail elderly. Dr. Gawande points out that in the early 20th century, 60 percent of elderly people lived with a family member, but that percentage has dropped to less than 25 percent. Those of us who do try to keep our elderly parents in our home or theirs are often faced with mounting caregiver and medical costs, emergency trips home, and runs to the hospital, as well as stresses on our spouses and children.

The alternative is assisted living followed by nursing home­type care. Dr. Gawande’s mother-in-law, Alice Hobson, was a vibrant woman with an independent spirit. When she became unstable on her feet and suffered memory lapses, she went into an assisted living facility on the urging of her son. Over time she incrementally lost control over such choices as when to take her medicine or when she could dine. The sense of autonomy and independence essential to Mrs. Hobson’s sense of self were traded for safety.

It was not a choice she made; it was a choice made for her. Ultimately she was transferred to a skilled nursing floor where she wasn’t allowed to wear her own clothes or wake up or bathe when she wished, and she shared a room with a succession of roommates chosen by someone else. The light seemed to go out of Mrs. Hobson’s eyes. In example after example, Gawande outlines the way in which safety trumps the need for relationships and autonomy by restricting residents to wheelchairs, insisting that medications be dispensed by nurses, and restricting waking, feeding, bathing, and retiring to inflexible schedules.

But what are the alternatives? Gawande asks us to consider that the medically dominated care of the elderly has valued safety, efficiency, and schedules over that which we all seek at any stage of life: autonomy and the ability to chose the risks and the trade-offs that we make in order to feel we have a decent quality of life. Perhaps Alice Hobson might have forgotten her medicine some days, but she would have preferred that to walking down the hall to the nursing station to request it.

Certainly there are limitations to what is possible with the frail elderly, but in Being Mortal we are offered some fascinating alternatives. Consider the story of Dr. Bill Thomas. When he came on as the director of Chase Memorial Nursing Home, in New Berlin, New York,  it housed 80 very disabled seniors. Seeing “despair in every room,” Dr. Thomas first tried medical interventions. Not seeing any real improvement. Dr. Thomas took another route. He brought in two dogs, four cats, and one hundred parakeets, and later added a colony of rabbits, hundreds of live indoor plants, on-site child care for the staff, and an after-school program. As they were able, residents participated in these ventures in a variety of ways. Research showed that, compared with residents in another home, residents at Chase took half the number of prescription drugs per resident, and deaths declined by 15 percent. We all need something to live for no matter what our age; we all need social engagement; we all need the sense that our presence matters.

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