A few weeks ago, I was behind a car with a rear-window decal that read “Midwives help people out.” If midwives usher people into life, hospice ushers them out, with much the same non-invasive and natural philosophy of, respectively, life and death.
A few days later I read an old blog post by a pastor friend confirming my thought. “It’s one work that faces in different directions. In one, releasing efforts to [hold on] and trust the new life wanting to birth through them. In the other, letting go in order to embrace the next stage. Both are bridging the past and the future” (Mahan Siler).
When I told a friend, a former hospice chaplain, that my mother has seemed better in some not-quite-definable way since hospice care began, she said she had often observed seeing people loosen their grip on control a bit, allowing themselves to move toward the next stage. (There is both sadness and relief in that for me.) Perhaps I, too, have let go of feeling like I have to be in control of all things, letting them carry some of the burden, as I observe a bit more (albeit fluctuating) patience in myself. Their call is to minister to the whole family, not only the patient. Mama’s doctors don’t do that, nor did home health in their brief sojourn with us (“And the Beat Goes On”).
The hospice nurse doesn’t think Mama will be able to stay in hospice beyond the three-month review. She can’t document decline, meaning her blood pressure, oxygen, heart are perfect; her strength undiminished. The nurse can’t see, in 30-minute weekly visits, the subtle changes in Mama’s memory and the abilities her decreasing vision robs her of—and Medicare doesn’t care about that anyway. When I saw the decal, my thought was that to qualify for a midwife-assisted birth there must be no existing complications; for a hospice-assisted death, there must be a documentable increase in complications.
I’m reading a book—that I bought, after dog-earring 20% of the first 50 pages of the library book containing passages I want to re-read or share—by Atul Gawnade. Being Mortal is about the inescapable realities of aging and death, and about how what medicine can do often runs counter to what it should do. It’s appalling the suffering modern medicine has inflicted on families and individuals in the name of a desire to achieve the impossible: eternal life. Dr. Gawnade shares a portrait of what happens to the body as we age. And it happens to everyone who lives long enough to experience it. It’s fascinating, especially living cheek to jowl with my mother.
But this post is about how this country cares for our increasing number of old-old. I will save the aging process for another post. Dr. Gawande reports a study from the University of Minnesota several years ago that found patients who had seen a geriatrics team were 25% less likely to become disabled and half as likely to develop depression. They were 40% less likely to require home health. A few months after the study results were published, the University closed their geriatrics division and the twenty members of the proven geriatrics team were laid off. The University couldn’t sustain the financial losses that insurance wouldn’t pay for (Gawande, p. 44). Gawande muses that if scientists could develop an implantable device that would give the same stunning results, there would be a campaign demanding that insurers pay for it and that every person over 75 have one.
Gawande asked the lead researcher what could be done to ensure that there are enough geriatricians for the surging elderly population. “Nothing,” he said. “It’s too late.” Gawande says, “Creating geriatric specialists takes time, and we already have far too few. Not nearly enough doctors will complete training in the U.S. (other countries are no better, some are worse) to replace geriatricians who are retiring, let alone meet the needs of the next decade.” There are no geriatricians closer to us than Seattle—two hours away and two hours back (on a good traffic day), a trek that is exhausting for both of us. But there is an amazing hospice team that meets Mama where she is. We have one more month until evaluation.
There are eight “Activities of Daily Living” required for basic physical independence: use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk. Medicare will pay for the help and equipment needed to do any of these in the home. Mama can do all of them.
Of the eight “Independent Activities of Daily Living” required to live safely on your own— shop for yourself, prepare your own food, maintain your housekeeping, do your laundry, manage your medications, make phone calls, travel on your own, and handle your finances—Mama can do none. She is almost 100% dependent on me and her other care partners for these necessary tasks. Medicare pays for none of them; and yet having help to do them keeps the elderly out of the hospital and expensive care units, which insurance would pay for.
The statistics of the number of family caregivers who get sick themselves (requiring premature care) following the death of their loved one is a disgrace. I am part of a group of family caregivers, many of whom are wives—themselves elderly—caring for husbands, with little or no help. It worries me for them. Yet, what are the options for people who can’t afford in-home care or don’t have unpaid family members able to help? Government supported institutional care, I guess. Someone else can do that math.
I am blown away by hospice’s service to the dying, just as I am of the work of midwives bringing forth new life. A lifetime ago I wanted to be a midwife, and later dreamed of being a doula. And now I am a doula, assisting my mother toward letting go. Sometimes we misread the call.