Stepping Out Into Aged Care - Acknowledging Possibility
Dr Bernard Leuthart
Issue 12, April 2004
The potent imagery of the dance is fascinating for the rich storehouse of metaphor it offers for elaborating on the type of movement potentiated in the work of the caring ministries. American educator, Maria Harris draws here on the wisdom of one Bill Maroon – a student of haiku somewhere - who offered this potent snippet as a metaphor for the sort of interaction that happens in the teaching moment between the learner and the learned.
We meet awkwardly
I invite you to walk
I find you dancing.
The image serves well in describing so aptly the sometimes stilted, sometimes wonderfully fluid movement that can characterize engagement with elderly patients in General Practice care. It also reinforces the sense of discovering real possibility beyond the pedestrian – possibility that exists almost invariably in encounters with older patients.
The dance imagery is powerful because the real nature of progression with an aging patient in general practice care especially is based not on steps as on a ladder, but steps as in a dance. It's a backwards and forwards serpiginous movement – making ground here, losing it there. The aging patient, it seems, draws us inexorably on to shifting ground.
What confronts the general practitioner at the fresh end of novitiate is a daily quarter-hourly balancing act that demands much beyond the clinical and draws frequently on a spiritual and ethical savoir faire/dimension not written hard in the received rules of engagement for doctor and patient.
Against the desire to be thoroughly effective and clinically safe in fifteen minutes is the need to balance the fact that older patients (often overtly) demand more time. They bring a larger number of often more complex problems. The chronic nature of medical problems in the elderly raises its own issues: same again? Or some new, insidious dimension in their presentation?
Against the desire for the quick neat summary of symptoms and progression is the need to balance the issue of pace – not wanting to rush the older patient when their issues are so embedded in a complex knit of superflua and past history. This is frequently a history requiring several encounters to appreciate in order to more reasonably comprehend the old person – well-layered, tentative, garrulous or querulous beside the desk.
The art of the matter here, it seems, is in learning to discern and wonder at the dichotomous nature of the old: the ordinary and the extraordinary in wild tension within them. The skill – and the creativity – seems to be in managing the gradual shift in control that happens in the lives of elderly patients becoming less independent and seemingly less autonomous. How to embrace that aging partner on your dance card when the lively quick-step falls to the shambling pace of the shuffle?
On this note, Ruby's case is perhaps a useful illustration.
Ruby presents as a handsomely-fashioned, independent woman of eighty-plus years. Previously an allied health professional herself, she has a witty, incisive intelligence about her. She is vibrant, opinionated, scoliotic. She is getting old. Until recently, astoundingly, she has been a gym junkie – despite mild heart failure, angina, hypothyroidism and cataract repairs. She drives enthusiastically. But in the last twelve months, Ruby has become acutely, despondently aware, of her declining capacity to meet life head-on.
The dance with Ruby begins in January. Her doctor is thrilled by her verve. In March, despite regular gym and weights sessions, she is dismayed and exasperated at becoming weaker. Her doctor is nonetheless impressed, and urges her on. In April, she travels to Australia, but feels disconcerted by her lack of energy. Her doctor prescribes continuing efforts.
One day in May, an episode of palpitations and dizziness at the gym sees Ruby transported away in an ambulance – a significant, personally diminishing event for her. Her doctor wonders if she overdid it that day.
By July, Ruby declares that she's giving up the gym and resigns to 'blobbing out more'. She worries that somehow she might 'forget to breathe'. Her doctor is somewhat disconcerted himself and exhorts her to hold that fitness mindset!
Early August and Ruby complains of tiredness and 'some cardiac paranoia'. The stairs at home are now a challenge. On examination, she is now in mild heart failure. Her doctor now is dismayed and thinks; 'Ruby, pull yourself together.'
In mid-September, Ruby presents low in mood and tired. She confesses to diminished confidence through 'unresolved traumas'. She feels anxious, neurotic and isolated. Her doctor, finally, pauses and draws breath. The empowerment strategy is demanding renovation.
The doctor's compelling desire to empower Ruby with exhortations to maintain her fit and vibrant tack on life was doing harm. What she had previously been seeking over months was the permission of her doctor to slow down, acknowledge her aging pump and be helped to re-form herself within a new normal. What objectively (or ideally) formed itself as a stand for her autonomy – for her decision-making and self-direction – was in fact effectively reinforcing her sense of invalidation because of new limits and loss she felt unable to overcome.
An issue with Ruby had become – at a point of crisis – the balance between empowerment and endorsement of individual autonomous function versus a more directive form of care which might give permission for her to slow down and become more interdependent within the community of care in which her family doctor is a key figure. Far from offering a robust solution, the GP was increasing her vulnerability.
Ruby herself is frank and lucid about her situation. She acknowledges a time of serious flux, fragility and intense loneliness for her. Her sense of frustration at her 'fierce independence' being compromised is overwhelming. She resents deeply her loss of autonomy and is not sure how far a community of care advocating for her makes her feel any less vulnerable and frustrated, and wanting to curse the darkness.
In finding a way forward with Ruby and others, it behoves us to develop a mindset for the elderly which embraces possibility. The Rubies, Irises, Marigolds, Daisies and Freds can all be found dancing. They can surprise us if we make an approach that invites them at least to accompaniment in moving through their issues.
There are some imperatives, perhaps. Actively attempt to tap into the sense of self-worth of the elderly patient. This dimension shapes any interpretation of their autonomy. Set out to dig the humus of them – the spiritual dirt especially – in order to understand what it is that has made and may still make them flourish. Most particularly, get a disposition/pattern for encounter that enables connection.
Maria Harris, the American religious educator cited above, offers a model for how this might be done. Initially modeled for the teaching encounter, this approach suits beautifully the pace of the older person.
Bringing imagination to bear on an encounter with the elderly in general practice asks first for contemplation, encountering, as philosopher Martin Buber puts it, 'a thou' there. Perceiving the 'thou' in whom we might sense mystery, the mystical, the numinous. Contemplation allows for the possibility that our engagement might open us to something approaching reverence.
What next? Engagement is next. Engagement amounts to the emptying of the subjective ego and opening to the person present there. It's the establishing (again and again) of the covenant between each other there, through which trust comes and grace is allowed to work. The whole project is under grace, implicitly.
Bringing on the concrete, form-giving is vital to the movement. Form-giving shapes the matter between doctor and patient, between co-learners. It allows for the possibility that something unexpected happens and directs outcomes and solutions.
The shaping of ends together is the step of emergence in the therapeutic relationship. 'Emergence' denotes that 'aha' experience where the ungainly and the indefinite might be elegantly bound up and where, like in good art, the ends are always emergent.
The attempt to deliver the patient to themselves, the moment of taking the hands away signifies the step of release. In doctoring/mentoring terms, it is the time to do no-thing, the time for silence. It is the point at which we acknowledge possibility most completely.
In conclusion, the spiritually creative imagination brought to bear on the work of healing and accompaniment with the elderly has a prospective and explorative quality which can open up enormous possibilities in our encounters in the caring ministries. It invites us to engagement beyond the pedestrian, to a more fluid and lively movement. It invites us to quicken our step.
Dr Bernard Leuthart is a General Practitioner at the Waiwhetu Medical Centre, Lower Hutt. This article is based on a speech given by the author at The Nathaniel Centre's Inaugural Conference 'Spiritual and Ethical Issues in Aged Care' in November 2003.
A full list of citations is available from The Nathaniel Centre on request.