Handbook for Mortals : Learning about specific illnesses : Dying when very old

When you are very old and dying, you may have different concerns than would a younger person. You may find your wishes about care near the end of life are in conflict with those of your family members or friends. You may find that you have come to feel comfortable with the thought of death, especially if your spouse and close friends have passed away. Picture of an elderly woman Younger relatives and friends may wish to seek out new medical treatments for your disease, while you may be more content to put off dealing with medical things and put comfort first. Your son or daughter, for instance, may wish to try every treatment to keep you alive, in part because that seems to be what it takes to be a good child. Even older adult children must grapple with what it will mean to be motherless or fatherless.

Conversely, you may find yourself alone. You may no longer have family and friends alive and may count on acquaintances for caregiving support. As you become weaker with your illnesses and age, you may find that you feel isolated from your community. Your routine may change. Instead of going to the supermarket on Mondays, a club event on Wednesdays, and church or synagogue over the weekend, you can only muster the energy to make all the arrangements for a trip to the doctor's office every month. Make sure you communicate your needs to members of your community. People from church or other organizations to which you belong may feel awkward dropping in uninvited but would be pleased to help you with a chore if asked.

You may wish to maintain your independence for as long as possible and avoid asking others to help. However, making connections now can prove valuable should your strength diminish. Also, having many supports decreases your chance of becoming isolated. Ask neighbors to call you before they head to the grocery store so that they can pick up small items for you. You may even ask for a non-essential item, such as candy, so that you can look forward to a visit (and give some of the candy to the child who does the delivery).

Advance planning is fairly obvious but often ignored. You really need to have plans in place for what to do if you are suddenly very sick and likely to die. Will your doctor come to your home? Is there a point when the various illnesses are enough to make hospice available to you? Can you have a skilled nurse who will come? Will you go to a nursing home at some point? There are a lot of uncertainties, and many of the possibilities will seem pretty troubling. However, remember that few will actually happen, and that it is better that they work out in the way you want, rather than for some unknown emergency room doctor to be deciding your fate.

Your physical appearance is probably still very important to you. Ask a neighbor to take you for haircuts or manicures. Having someone talking and making you look better will uplift your spirits.

While you may enjoy getting dressed for outings, take care not to over- or underdress. Pay attention to the weather and use layers accordingly. You may feel inappropriate if you do not wear a suit to events where you usually do so, but it would be unwise to wear one in 95-degree weather. As you age, your natural thermostat does not work as well as it used to and you could overheat. Also, numerous medications could make your blood pressure drop - and make you feel quite dizzy if you stand up quickly. Similarly, you should prepare for cold weather by always having a sweater or jacket available. You may or may not have been in the habit of routine exercise. While you may no longer be able to take long walks, you need to do some exercises of the upper or lower body in order to maintain some muscle strength. This routine is important to prevent dependence on others. You may be more motivated to exercise if you do it with music. Playing the same song every time you exercise will help to establish a routine. Here is a sample routine:

As you age, your senses of taste and smell diminish, so that you will find it more difficult than a younger person to enjoy food. Much to your surprise, you may find that you enjoy adding strong flavors - vinegar, hot spices, aromatic spices, and pepper. Also, you may have dentures and find it difficult to chew certain foods, such as meats. Supplemental protein drinks, cheeses, eggs, or peanut butter can be good substitutes. Multigrain crackers eaten with the peanut butter or cheese may decrease the likelihood of constipation. Do not concern yourself with eating a low-cholesterol diet. You should eat what tastes good, even if it is ice cream.

Vegetable juice or vegetable soup may be easier to digest than cooked vegetables. If possible, take a multivitamin with minerals each day. If, however, these pills are too large to swallow, have a family member cut them in half, or get the liquid or chewable forms made for children (and have your doctor or nurse help figure out how much to take).

You may find salty foods, such as crackers or nuts, more tasty than others. Do not restrict these if they taste good unless you have certain illnesses such as congestive heart failure or hypertension and your health care provider has recommended decreasing the salt in your diet. Be sure to ask the health care provider about whether dietary restrictions still apply. Your doctor may have told you years ago to be careful about salt intake or cholesterol in your diet, but the situation may be different as you age. For instance, your mild high blood pressure and subsequent need for salt restriction may disappear because you have lost weight.

When your appetite is poor, the thought of a large meal may worsen it. If a neighbor or friend brings over a large meal, or if you receive it from a community service agency such as Meals on Wheels, dish a third of the meal onto a dinner plate and eat only that amount. Save the rest for another time. Unlike a child who is eating to grow, you are eating just to enjoy yourself and to give yourself energy to manage the things you want to do each day.

Like other elders, you may be living with more than one illness or condition. You may suffer from osteoporosis and osteoarthritis as well as a newfound cancer. You may have coped fairly well with these chronic diseases but find yourself overwhelmed by the prospect of dealing with another illness. Also, you may be concerned that treatments and medications may interact. This is a valid concern. Be sure to inform your doctors and nurses about how you cope with your other illnesses.

Many elderly persons have some urinary incontinence. This, unfortunately, can worsen with many medications and some medical treatments. For instance, radiation or surgery done to treat prostate cancer usually worsens urinary incontinence. Do not give up your life because of this condition. Some persons with urinary incontinence dislike going out of the house for fear of having an accident. This further isolates them from their community. Try out all the new pads and underwear that can really keep you secure. Also, discuss this condition with your health care provider and ask if certain medications are still needed. For instance, diuretics, which are often used to treat hypertension, can worsen incontinence. Ask if they are still necessary. There are medical and surgical treatments for incontinence, but often patients are reluctant to discuss the condition.

If you are elderly, you may be the last remaining member of your generation or at least the last person living in your house. As you get your affairs in order, it is, of course, important to make a will, but it is also necessary to give certain loved items to friends or members of your family. Don't assume that your only great-grandchild will find the antique doll in your closet and keep it for her own. If you have a strong opinion about who gets what, write it down. You don't want family members squabbling. You may enjoy giving the gift while you are still alive!

As an older person, you may have strong religious convictions. You may regret not getting out to your place of worship as often as you used to. You may miss both the spiritual and the fellowship aspects of the services. Communicate with church, synagogue, or mosque leaders and ask if the services can be brought to you. Ask them to tape the services so that you may listen. Tell them that you would like a few members of the choir to come over and sing. Ask the pastor for a reprint of his or her sermon. Try to stay connected with the congregation.

Getting to live to old age is probably the supreme accomplishment of our society. Once, very few had the chance, but now most will. However, we do not yet have the social arrangements that ensure that you can live comfortably and meaningfully in your eighties and nineties and beyond. You and your family will have to confront some social arrangements directly and find what will work best for you, your illnesses, your family situation, and your finances. It seems to help to keep the spiritual issues in mind, rather than letting medical problems and practical arrangements take over all of your attention. Push yourself and your family, at least a little, to enjoy some time doing things for one another, telling stories, voicing love and forgiveness, and so on. Those will be the shared experiences that get you through hard times, and those will be the times that your family and friends will remember with fondness.

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Handbook for Mortals book cover Copyright © 1999, 2006 by Joanne Lynn. This extract from the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D. is used with permission. To learn more about improving care at the end of life visit the main web site for Americans for Better Care of the Dying.
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