An earlier version of this article incorrectly stated the height of the author's father. This version has been corrected.
What Are We Going To Do With Dad?
My father is 86 years old. He was never a big man, except perhaps to me when I was his little boy. At most he was 5 feet 8 inches tall and weighed 160 pounds. Today he weighs barely 120. Maybe he is 5 foot 2. He teeters on spindly legs, a parched blade of grass in the wind, refusing the walker his doctor recommends or the arm extended by those of us who love him. He doesn't know what day it is. Shaving exhausts him. His clothes hang like a scarecrow's. He is nearly deaf but won't wear his hearing aids or loses them as often as a kid might misplace his marbles. He drives my mother -- five years younger -- crazy to tears.
My only sibling, an architect, asks me every time we are together (which is often because we all live in San Antonio) and every time we speak on the phone (which is almost every day because we are a close family now in crisis): "What are we going to do with Dad?" As if there must be a definitive answer, some fix -- say, putting a grab bar in the bathroom or increasing the width of the doorways.
He asks me this question not just out of fear and frustration, but because he figures that his older brother, the physician, should know the answer. I do not know the answer. I do not have a pat solution for my father or yours -- neither as a son, a man past middle age with grown children of his own, nor as a specialist in geriatrics who is also a credentialed long-term care medical director.
In the United States today there are 35 million geriatric patients -- defined as over the age of 65. Of these, 4.5 million are older than 85, now characterized as the "old old." Yet the American Medical Directors Association, which credentials physicians in long-term care, has certified only 1,900 such doctors in the entire country; only 2 percent of physicians in training say they want to go into geriatric care. As we baby boomers go about our lives, frozen into our routines of work and family responsibilities, a vast inland sea of elders is building. By 2020 there will be an estimated 53 million Americans older than 65, 6.5 million of whom will be "old old." Many of you will be among them. America will be inundated with old folks, each with a unique set of circumstances, medical and financial.
Compounding all of this is the sad and frustrating fact that our government appears to have no policy vision for long-term elder care. It's as if our leaders wish -- perhaps reflecting our collective yearnings as a vain, youth-worshiping society -- that when the time comes, the elderly will take their shuffling tired selves, their drooling and incontinence, their demented ravings, their drain on family and national resources, and sprawl out on an ice floe to be carried off to a white, comforting place, never to be heard from again.
For the past nine years I have been the medical director of my hospital's skilled nursing unit, or SNU. This unit receives patients from other parts of the hospital who no longer need acute care services yet are unable to return home. Sometimes it is obvious what we have to do: finish out a course of intravenous antibiotics or provide a few more days of rehab to a competent elder who has just undergone a hip replacement. But more and more, as our patients grow older and more frail, it becomes clear that the attending physicians have referred their patients to the SNU because they don't know what else to do with them.
Each week I attend the SNU team care conference. Every staff professional who has a role in patient care attends. The nurses provide up-to-the-minute reports on each patient's medical progress; the therapists discuss whether the patient is meeting goals set the previous week; we hear about the situation at home, what help we can expect from family or other caretakers, and what the patient's insurance may or may not provide. Our main goal is to answer one question: What are we going to do with this patient? Where can we safely send him -- given his medical, social and financial circumstances -- and expect him to maintain his highest level of functioning, his remaining dignity? Very often, we don't know.
Families are encouraged to join us after our review. Most do not -- often, I think, because they are afraid we will tell them there is nothing more we can do. They are already despondent, overwhelmed by Dad's (or Mom's) decline and the acute event that led to hospitalization (the pneumonia, the fall, the stroke); bewildered by his mental decline (the confusion, the weakness); frustrated in dealing with the hospital staff (the inattentive aides, the callous nurses, the harried attending physicians who often drift in and out like white-coated apparitions).
So now your dad's physician -- maybe the one person you trusted to solve all of this (although less and less so in these days of managed care, because it is hard to trust someone you might have just met or whose name was picked at random from a list of names) -- comes into his room and says, "I don't think there is much more we can do for him here."
Your mind reels. Nothing more to do? In America? Home of the most advanced health care in the world? You think about all the glowing seniors -- continent, smiling, sexually active -- in those drug ads on TV or the aging but robust movie stars on the cover of the AARP magazine. Nothing to do?! You gotta be kidding, doc! And anyway, he was just fine until he came to the hospital!
The doctor sighs. She has been through this many times and still doesn't quite know how to handle it. Even though the ravages of aging are not her fault, she feels the stern gaze of Hippocrates on her back and wants to do more. She might remind you -- tactfully -- that this patient, your father, lying with sallow distorted face, partial paralysis, a Foley catheter draining his urine into a bag clipped to the bedrail, was not fine when he came to the hospital. He was not shanghaied from home while smoking his pipe and reading the Wall Street Journal. Rather, he arrived in the ER at 4 a.m., hypertensive and gurgling, brought in by ambulance after he passed out and hit his head on the toilet.
"I think perhaps we can transfer your father to our skilled nursing unit for some rehabilitation," the doctor says. I say it all the time. Family members are uncertain what this means but temporarily grateful: The doctor has postponed answering the "What are we going to do with Dad?" question for a while longer.