He is also a partner in a communications firm operating in Canada and the U. He lives in Toronto. Parenting Your Parents Primary tabs View active tab Preview Overview When our parents reach a certain age and have difficulty coping, we find ourselves wondering how to provide them with the kind of love, care, support, and attention they need - just as they have done for us all our lives. Mindszenthy Follow this author. Michael Gordon Follow this author. Other titles by these authors.
In fact, she found she could once again play canasta with her friends. Now, however, Lee Ann has developed a malignant tumour in her colon that is still relatively small but has the potential to grow and spread. Her doctor believes surgery will be required at some point. As well, she is in constant pain because of severe osteoarthritis in her left hip, and a hip replacement operation is the only certain way to help her with that condition. The colon surgery, on the other hand, is more urgent because of the risk of the tumour spreading.
Lee Ann understands that she needs the colon surgery, and she also wants the hip replacement, but she is fearful of the two operations and the period of convalescence that would follow. Sylvia knows that her mother would like to live with her and Gerry during her recovery. Gerry is against this idea because they live in a small house with two bedrooms, and they both work full-time.
David has said that he wants to be supportive but that distance prevents him from doing much in terms of hands-on help. The challenge for the family is how to help Lee Ann face two surgical procedures, both of which are necessary to give her a chance of survival and an improved quality of life. How can they help without disrupting their own equilibrium in an unacceptable way?
The family faces several important issues. Should the colon surgery be performed first? If so, Lee Ann would require at least two or three weeks of in-home care. But where should she stay for that period of time? If she were to remain in her apartment, she would require professional home care services, as well as someone to live with her during her convalescence.
Or, could Lee Ann stay with Sylvia and her family, or with David and his partner? Could David take a few weeks off and stay with his mother? If the colon surgery is performed first and Lee Ann has a good recovery, then should the orthopedic surgery be undertaken to replace her left hip? And if so, when? Rehabilitation work would be necessary 42 S URGERY after the hip surgery, and that would mean Lee Ann would have to be taken for rehab sessions at least twice a week for several weeks. Sylvia and Gerry have talked about what they could and should do.
Their son, Jay, is relatively independent but works long hours. Sylvia has discussed the situation with her brother during the course of several telephone conversations. David listened to the case Sylvia presented but responded by saying that Mary was really counting on having their holidays together for a long-planned drive to tour the Grand Canyon and to spend time in Las Vegas.
This has irritated Sylvia, but the siblings have stayed very polite with each other. It is worth dividing the issues into those that are mainly clinical and those that are related to the way the family feels they should and can support Lee Ann, who wants to remain independent, but who is facing some difficult challenges in the next little while. When considering the clinical issues, the priority is likely going to be the removal of the colon tumour.
It is worth asking the surgeon if the surgery can be done in such a way that bowel function will be maintained and a colostomy exit of bowel through the skin will not be required. The answer will have a big impact on the type of care required immediately after the surgery and for the longer term following. Also, the assumption is that the tumour will be contained and will not spread metastasize to other organs, so that the outlook over a longer period of time would be good.
However, until the surgery is done it is hard to know whether further treatments such as radiation therapy might be required. The family must understand that there is some urgency to the decision about the colon surgery and that they must find ways to support their mother through this emotionally and physically trying situation. Although Lee Ann may be holding herself together in face of what is probably a very frightening prospect, it appears that she does not want to be a burden on her family. This is the time for her children to find the means to rally around and support their mother, one way or another, within the resources, human and otherwise, that they have available.
They can look at the challenges in a few stages. The first is the immediate preparation for surgery, with its emotional and physical impacts. This is the time for everyone to find time and, in a co-operative fashion, to be there to bolster their mother and grandmother. Although such assistance often does not completely replace the need for family, it can provide proper care for the patient while families carry on with their other responsibilities.
Reactivation programs in long-term care facilities may be available in some jurisdictions, and home care options, providing nursing care and some homemaking, may be available as part of the health care program. These services may have to be supplemented through paid help in 44 S URGERY addition to whatever the family can weave together to support their mother in getting over the immediate post-operative and return-tohome period. It would be worth exploring whether there are friends and neighbours available to give a little help.
In fact, such help may very well be readily forthcoming and may pleasantly surprise the family and Lee Ann. Although the family may not want to impose on others, often neighbours and friends feel that helping out is one of the ways to demonstrate affection and caring, so the idea of asking for help should not be dismissed out of hand.
As for David, this is a time to test his relationships. The way everyone comes together in this time of need will be a reflection of the fabric of this family. Anyone can be constructive and positive when there are no demands. First, if the colon surgery goes well, that experience should help Lee Ann and her family understand the steps necessary to negotiate the health care and home care systems. Second, there are often programs in place to assist in the rehabilitation process following major orthopaedic surgery. It would be wise for Lee Ann to wait at least three months after the colon surgery to have the hip operation.
This should give her ample time to regain her emotional and physical strength and her independence. If more time for recovery is required, then the hip surgery should be done later, as the urgency for it is not great. If it does, arrangements should be made after discussions with the orthopaedic surgeon and, if appropriate, the social service department of the hospital to make certain that the post-operative plan includes admission at an in-patient rehabilitation unit. Following anywhere from four to six weeks on a rehabilitation unit, Lee Ann will in all likelihood be able to return home with minimal assistance.
If the hip replacement will make Lee Ann more independent than she was prior to surgery, it is likely that little, if anything, will have to be done to the home to meet her needs. However, some safety measures might be recommended, especially in the bathroom to make sure she can bathe safely with minimal risk of falling. If Lee Ann and her children are concerned about Lee Ann being alone in her home, they can look into an emergency response system, such as Lifeline see the Resource Directory at the back of the book , which allows individuals to call for help should they fall or injure themselves, providing a sense of security to clients and their families.
Illness poses a great challenge both to those affected by the illness and to their families. This is a special time for families to enrich their 46 S URGERY relationships and to demonstrate what they are willing and able to do for their loved one. It has to be a co-operative affair so that there is no lingering resentment that can cause hard feelings later. What better way to demonstrate affection to a parent in special need, even the most independent parent, than to help as an act of love and devotion? That is what families are all about. Born in Costa Rica, he moved to Canada in the early s and two years later married Kate, a Canadian woman he had met a year earlier.
They lived for some twenty years in Dartmouth, Nova Scotia, where Raul worked in the shipyards until he retired in Raul has a son, Ramon, from a previous marriage, who remained in Costa Rica and over the years built a successful restaurant business. However, Ramon felt closer to Mandy. Yet whenever Ramon visited, he tended to dominate the relationships.
During the winter of , Raul slipped and fell on an icy patch of sidewalk while walking to his nearby grocery store. He suffered what was diagnosed as a mild concussion, broke his right arm, and fractured his right pelvis. For weeks following his release from the hospital, Mandy spent several hours every day at his apartment caring for her father and spending time with him. She did all his shopping and prepared all his meals, while helping Raul adjust to using only his left arm and hand.
Since Raul also was relatively immobile because of the fractured pelvis, Mandy helped him get out of bed in the morning and into bed at night until he was able to function again. Ramon paid a hurried visit the following week and spent two days with his father. During the visit, he urged his father to return to Costa Rica. Ramon told Raul that his business was starting to prosper and that he would look after him much better than Mandy had been. Meanwhile, Mandy continued to look after her father. She arranged for special support services and physiotherapy sessions. For months following his fall, Raul seemed to be making real progress with his recovery.
Then one morning, he lost his balance getting out his bathtub and fell. While he was diagnosed with nothing more severe than some bruises and a twisted ankle, somehow Raul seemed less able to recover. In fact, he required more attention and support.
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Mandy arranged for in-home support and more physiotherapy sessions. But walking was now much more difficult for Raul, and he relied more and more on using a walker. Whenever Mandy took him outdoors, he was now in a wheelchair.
Over the following year, Raul became more and more reclusive and less and less certain of himself and his ability to walk. He predicted Raul would enjoy and benefit from the warm weather and change of scenery and that the visit would be good for his health. He insisted that any medical needs could be arranged easily and quickly. Raul was more receptive this time. After a long winter, and feeling depressed about his condition, Raul told Mandy that perhaps a few weeks in his homeland would be good for him. She challenged her father and Ramon, telling them that her father needed special care and that she had worked hard to arrange for him to get that care on a regular basis.
She said that while the climate might be wonderful, there were just too many unknowns, and the possible risks outweighed the benefits. While her father wavered and became indecisive, Ramon became all the more adamant. He argued passionately that his father had a right to go home and enjoy himself. On the one hand, she loved her father and worried about his health and well-being.
She was now confused and uncertain, but she felt a nagging concern about the dangers of such a major trip for her father at his age and in his condition. When the travel situation is more complex, as in this case, it is important to examine all the issues and implications of the travel itself, as well as the stay in the faraway place. Only then should the trip to Costa Rica be contemplated. It is also very unfair to try to direct the decision to Raul, who clearly is caught between his two children and would like to please both of them in addition to wanting to feel better.
Their mutual priority should be the care and well-being of their father.
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They must put aside their own needs, even the ones couched as concern for their father. Ramon would like his father in Costa Rica for a number of reasons, but one might very well be so that he can demonstrate to his friends and family just how much he cares for his father, something he cannot do from afar. The real challenge for Mandy is to approach Ramon on general terms regarding their mutual care of their father. It probably would be worthwhile for Mandy to find a way to speak to Ramon openly and tell him that she is not necessarily opposed to Raul visiting Costa Rica for a short period, but that the trip must take place within a framework of a plan for the present and future of which they are both a part.
The benefits would be that their father could finally feel comfortable knowing that the two of them have found a way to bridge their differences, which is something that a parent always wants. Ramon may not be aware of just how trying their lack of closeness has been for Raul, and anything that might make him feel better would be very important to him in these waning days of his life.
It might even be worthwhile to pursue whether Mandy could join her father on the trip to Costa Rica and be involved in his time there. That would probably be very meaningful for Raul and also possibly improve the relationship between Mandy and Ramon. Even if Mandy cannot stay for the whole trip, going on the flight and staying a few days to help get things settled would be beneficial if it could be arranged.
As for the trip itself, there are certain basic principles that should be kept in mind when frail seniors undertake longer trips, especially by air. The Medical Condition One should not travel if a medical condition exists that requires frequent monitoring and has resulted in repeated, unexpected admissions to hospitals or emergency rooms. Most insurance companies will not cover individuals with such uncertain medical conditions.
One guide insurance companies often use, sometimes erroneously, is whether changes to medications have occurred during a previously defined period often ninety days. This guide sometimes does not make medical sense, as in the case of the discontinuation of a medication that is no longer necessary or a decrease in dosage because of better outcomes of an already established treatment. The reasons for any changes, especially positive ones, should be documented by the physician to make sure that, should something happen, there is a good sound explanation available that would not imply increased risk during the trip.
The risk of not being covered is potentially huge medical bills, especially, but not exclusively, from illness that occurs while outside the country. To travel without such insurance is financially very risky. The Travel Itself The trip itself might pose many problems and barriers, especially with the very long waits at airports due to heightened security. This might be a problem for frail, elderly individuals such as Raul. Problems with behaviour or potential agitation may also be reasons not to attempt to fly, as they are difficult to deal with on a plane and not fair to other passengers.
If Raul needs a wheelchair, for instance, that has to be arranged in advance with both airports. It is important to make sure that all necessary supplies, including medications, continence supplies, and, if there is a risk, a change of clothes, are easily accessible. Benefits of Destination The benefits of the trip should be weighed carefully.
Can the trip be arranged so that it is safe? Will it relieve the person of having to face a bad winter? Will it reunite the person with a loved one? It is always necessary to make sure that there will be appropriate support and supervision to decrease potential danger. How necessary medical services will be provided and by whom, as well as who should be contacted in case of an emergency, must be determined before travel. Travel is not as easy as it once was. With good planning many people can travel safely and enjoy the benefits of warmer climates, especially during our harsh Canadian winters.
If the warmer climate is part of the rationale for this trip, then Ramon has to find a way to discuss openly with Mandy and if possible Raul all the implications of the trip. If there is such a chance, it might be worth the effort and potential risk. If not, and the trip might lead to further conflict and put Raul at unnecessary risk, perhaps it should be rejected as a viable option. The result is increased family tension and parental angst. Their eventual arrival here is a story in itself. He was, however, assigned to work in a factory several hundred kilometres from his village.
Two months before the end of the war, after nearly a year at the factory, he managed to escape, work his way back to his village, and reunite for one night with his family and wife. Under the deep cover of the next night, he and his young wife, Sophie, left their native village in the Ukraine with only the clothes on their backs and a satchel full of food. They managed to reach the Austrian boarder just as the war ended, and they were two of the first few to be accepted into an Austrian refugee camp where they were interned for three years. They applied to both the United States and Canada for refugee status and were eventually linked through the Red Cross with a sponsor in Red Deer, Alberta.
The sponsor was a distant relative who agreed to help them settle in Canada. Ivan is now in his late seventies and Sophie is in her mid-seventies. No one is certain of their ages, and no birth record has ever been found. They have two sons: Boris, forty-nine, who was born in the Austrian refugee camp just months before the family came to Canada, and Bob, forty-one, who was born in Red Deer.
Both brothers left home some twenty years ago and now live in Montreal. Because the brothers are close to each other and comfortable with their lives in Montreal, they decided that to best help their parents, they should move them to a retirement home close to them. At the time of this decision, neither parent really wanted to leave Red Deer, where they had a number of friends and an active social life.
They were well known in the community because, from the mids to just two years ago, they had operated a popular diner known for its spicy cabbage rolls, various potato soups, and other ethnic dishes. But Boris and Bob were persistent. During their annual visits and weekly telephone calls, the brothers made their case and finally convinced their parents that they should move to Montreal.
Nine months later, Ivan and Sophie sold their home, shipped their belongings ahead, and a week later took the train to Montreal.
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But as they got older, they also longed to be closer to their sons, and they knew of no other way than moving to make that possible. Boris and Bob, who really are close to each other and very fond of their parents and proud of what they have done with their lives, were determined to make the move a good one.
After considerable searching, they found a small but attractive one-bedroom apartment for their parents, which they agreed to subsidize. They spent a full day putting the place in some kind of order that they thought would please their parents. When Ivan and Sophie arrived, Boris and his wife, Janet, and Bob and his wife, Adele, and their two children, Jennifer, twelve, and April, ten, met them at the station. She cried even more when she saw most of what was in her old home crammed into the small apartment.
And so began a new life in a new place for Ivan and Sophie. Now, months later, the euphoria of being reunited and living in the same city has waned. The first negative experience was when Ivan discovered that he was very intimidated driving in Montreal. The sheer volume of traffic scared him, and he found himself easily confused by the bilingual signs everywhere. Yet driving was important to him; having a car and being able to drive was, for Ivan, an important symbol of his independence.
Now he was hardly driving at all. Both Ivan and Sophie have found getting around the city without the help of their sons to be difficult, if not impossible. The subways are frightening, and they feel unsure of themselves on the escalators, in the subway cars, or even in knowing how to get to where they want to go.
They miss their friends and the city that for so long was home and that they knew so well. Neither Janet nor Adele call or come to visit very often, and when they do, or when Ivan and Sophie go to their homes for a visit or a meal, there is always a feeling of tension and discomfort. But just as hard to bear for Ivan and Sophie is that their two granddaughters are completely alien and show no interest in or respect for them. After nearly nine months in Montreal, Ivan and Sophie are miserable, lonely, dejected, and depressed. Meanwhile, Janet and Adele continue to lobby their husbands for more of their time, and for more time with their own parents.
Then, when their parents tell them they would rather return to Red Deer, the brothers are frustrated and angry. Both Boris and Bob have taken them to the Ukrainian Orthodox church in Montreal and to a Ukrainian social club, where they thought their parents would find some new friends. But their parents are adamant about their unhappiness and their desire to move back to Red Deer. We often have ideas of what people are like and how we can create situations that will ensure their happiness or at least contentment.
But these fantasies are often very different from the actualities of everyday life. Moving is hard for anyone, and a new situation is often fraught with unknown experiences and unanticipated responses. Whether a move is for work, study, or personal obligations, most people adapt out of necessity. And sometimes a move means immediate success — perhaps a better job, a nicer house, new challenges, and often new friends. But when a move happens later in life, it can be much more difficult. The shared memories and reference points for collective reminiscing, such an important part of social activity, is lost as the fabric of friends is disrupted by death or by a move away.
So what happened here with this clearly caring family that might have been averted, and is there any way to salvage the situation? First of all, a decision to move an older relative must be made with careful thought. A family can rarely be a sufficient substitute for a social network. Families may care for loved ones more in the deepest sense, but they cannot replace the normal social activities of a familiar circle of friends in a long-accustomed environment.
Before considering the move, Boris and Bob should have discussed with their parents what it was that they thought they would need in order to be reasonably satisfied, if not happy, in Montreal. A spouse or children can easily feel that their usual family time is lost when so much time and attention shifts to the care of elderly parents. This would have given Ivan and Sophie an opportunity to figure out what there is in the new community that might be attractive enough to make the move worthwhile, separate from the anticipated need to be with family as their faculties decline and health becomes compromised.
If, after a prolonged visit, Sophie and Ivan felt that they would likely be isolated, perhaps a permanent move would not have been contemplated. Some families choose to have a number of prolonged visits to provide an opportunity for the parents to explore and make some acquaintances that might form the nucleus of new friendships should a permanent move be undertaken.
The sons could not possibly fill the void left by the loss of the network that Ivan and Sophie had in Red Deer. Children are rarely friends with their parents, and the child-parent role is hard to change even in mature years. For their part, Ivan and Sophie should have had a heart-to-heart talk with each other to understand why they decided to make the move.
They needed to understand that while they would be losing some of their present happiness in Red Deer, they would at least be with family and feel secure should something go wrong. There is nothing wrong with that choice, but when they made it, they needed to decide to dedicate themselves to finding ways to make it work, rather than comparing their new situation to what they had before. Such a move could never result in their having the same milieu that existed with their friends in Red Deer.
But if they felt that the modest amount of loneliness and lack of social network was worth the investment in the future, then they might have come to terms with the trade-off. Clearly they had the strength during their younger years to make such a choice, but in later years it was less easy to do. Finally, Boris and Bob need not feel that they failed. They also cannot blame their families for letting their parents down. It would be an extraordinary family that could accept a major shift of attention from their lives to the needs of parents now living in the community without some feeling of resentment.
A frank discussion with everyone in the family, without any blame or suggestion that anyone is at fault, might help clear the air. A counsellor might help the discussion, but one is not necessary for this situation to be fully explored with everyone involved. Sometimes people imagine the past as being better than the present. Maybe, indeed, life would be better if Ivan and Sophie moved back to Red Deer.
But perhaps not. They may not be able to realign themselves with their previous network. They could try moving back for a few months, renting a suitable place that would not require them to move all their belongings again. Or, they could decide as a family that the future was so risky for Ivan and Sophie that everyone is going to have to sacrifice a bit for things to work out. Ivan and Sophie are going to have to discard their illusion that their life in Montreal is going to be as good as their life in Red Deer.
They need to figure out what they can do to make it as good as possible. They clearly had the strength to make difficult moves in the past, and now they have to draw on their strength to do it again. The attitude with which they undertake that task will go a long way in determining their success. I have seen many of my patients resist joining a club or taking on a volunteer position only to thank me later because of the successful outcome they had when they finally took a chance. This should include a commitment to spend a reasonable amount of time with them, knowing that in all likelihood things will improve with time if everyone is very caring and supportive in the beginning.
It is not too late to salvage the situation. Boris and Bob should admit to their parents that they made some mistakes moving them to Montreal, but tell them that there is a time to try to turn things around. Bob and Boris would not be able to provide that help in Red Deer, and Ivan and Sophie could end up quite isolated in that community. Ivan and Sophie should agree to give the move another try for about four months. During this time they could join some social groups and really make an effort to see what might happen if they attempted to meet people and develop a new network of friends.
The agreement might be that if, after four months of everyone trying their best to explore the relationship, build on its strengths, and understand the long-term benefits for the future, things are not better, Ivan and Sophie will move back to Red Deer. If so, Boris and Bob will not have failed, nor will have their families.
In due course the situation may resolve itself, if, for example, Ivan and Sophie need medical care in Red Deer and receive it there, or if they progressively deteriorate so that they cannot look after themselves but find somewhere to stay in that community. Or perhaps after one parent dies, the one who survives will accept that there are no real choices but to rejoin their children in Montreal.
No matter what decision is made, it is important to remember that this experience was not a failure, but merely a human attempt to be a loving family. She and her husband, Julio, moved to Canada from their native Italy in , the day after her twenty-fifth birthday. Eventually, though, she started cleaning homes in the area. She also spent considerable time babysitting for neighbours and even for some of the clients for whom she cleaned. And so cleaning and looking after young children became her full-time work for many years. In , when Fatima was thirty-seven and Julio forty-two, Fatima became pregnant and gave birth to their only child, Angela.
While both were delighted at the arrival of the child, it was a surprise coming fairly late in their lives. Fatima lavished time and attention on her daughter while still working five days a week cleaning homes and babysitting. Twice they made the pilgrimage back their old hometown in southern Italy, and over the years a few relatives came to visit them. Angela thrived in school and revelled in her cultural heritage.
She learned to speak fluent Italian and to read and write in the language. Her English was also flawless. She graduated with honours from high school and went on to earn a university degree in psychology with top grades. Once she finished her schooling, she found a job in a teen counselling centre. In her late twenties, Angela married Frank Combriani, a hardworking chartered accountant whose parents had also emigrated from Italy in the early s.
For the first few years of their marriage, Angela and Frank lived in a downtown apartment; later they bought a small house in suburban Scarborough. When Julio retired at age sixty-six, Fatima continued to babysit a few half-days a week. The extra income was welcome and she enjoyed the work.
Over the years she had gained a strong reputation for her skill with children. In fact, she was babysitting the children of some of those she had babysat years earlier. In their increasing free time, Julio and Fatima socialized, still staying for the most part in their Italian community.
Surgery was determined to be too risky, and his age further compounded the situation. Julio died two years ago. For a period of time after his death, Fatima continued to live on her own in their small home but found it increasingly difficult to manage. She explored the option of finding another woman to share the house with, but that seemed complicated. By this time they had a five-year-old son, Frank Jr. After much discussion and a lot of thinking, Fatima decided that perhaps it would be a good move. She loved her daughter, and she was very fond of Frank.
A month later, she made the move. Generally, the transition was good. Fatima liked her little room and her privacy, and she also liked spending time with her grandson. She especially liked her time with her daughter and son-in-law because they could speak comfortably in Italian. She would also watch a considerable amount of Italian television programming, and every few weeks Frank or Angela would take her to visit friends in her old neighbourhood. When it was time for Angela to go back to work, she asked her mother to babysit Gabby, since she was living with them anyway and it was clear she liked spending time with her.
As the months passed, both Frank and Angela noticed that Fatima seemed more withdrawn and, as they saw it, depressed. Finally, Angela called a nearby geriatric clinic to arrange an assessment and then broke the news to her mother. She told her mother that she was simply worried about her, and disguised her true concern by explaining that, given her age, Fatima needed to be seen by those specializing in the health of the elderly. Mother and daughter went to the clinic for the appointment.
The geriatrician first met with Fatima and Angela together, and Angela explained that her mother seemed increasingly depressed. She shared that her mother was withdrawn and preferred to spend more and more time in her room, whereas just months ago she seemed to really enjoy family interaction and playing with her grandchildren. Then the physician started his examination of Fatima alone, during which time he asked her what was going on from her perspective.
He noted that he could not find anything physically wrong with her but was concerned about her mood. She said she loved her grandchildren, but she wanted to enjoy them and not feel like she had to work at it five days a week. The geriatrician told her that she had to be honest with her daughter about her feelings, but Fatima initially balked, saying she did not want to hurt her daughter, whom she loved very much.
The doctor said he would help her explain and that everything would be all right. When the geriatrician told Angela what Fatima had said, Angela was shocked. Plus, they trusted Fatima with Gabby and Frank Jr.
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But mostly, Angela said, they had believed that her mother would thrive in looking after her grandchildren; this, after all, is what both remembered seeing so much of in their old Italian neighbourhood in their youth. Angela expressed regret that she had put her mother in this unfair situation and said she wanted to help resolve the situation in any way suitable to Fatima.
With this freedom bestowed on her, Fatima generously offered a few days a week to act in her loving grandmotherly role while knowing that she had the other days for herself, to explore and grow in areas that appealed to her. Many older women recall their childhood experiences when they were directed to choose a career path or personal direction based on assumptions of what was right for a girl. Of course, nowadays that is less common, and most mature women feel they have the right and personal obligation to fulfill their own interests and aspirations.
We may forget, however, that our parents may feel the same way, even though they have never had the chance to act that way in the past. An important key to mature and respectful relationships is open and honest communication. She felt trapped by the assumptions made by her daughter and her own true devotion to her child and her grandchildren.
She was even willing to make the personal sacrifice of not addressing the issue with her daughter, but her deep emotional strife manifested itself in her behaviour. It is fortunate that Angela, being a caring and sensitive daughter, sought to help her mother without realizing the source of her emotional problem. Fatima did not have the courage or perhaps the practice of expressing her own wishes or needs and accepted the situation rather than disappoint her daughter. This is where a knowledgeable and sensitive physician can play a crucial role in helping to solve a family problem.
The trust that most people feel toward their doctor allows the physician to use his or her experience and knowledge to influence the decisions that families make. In this case, giving Fatima the opportunity to express herself privately to the doctor, away from her daughter, was key to figuring out what was going on. All older patients, when visiting a doctor, especially a new one, should have the opportunity to speak to the doctor alone and in confidence, if they are able to do so. Many doctors structure their interview to include all family members during the initial history taking and then examine the patient alone, thereby allowing the person to express his or her own feelings in private.
Doctors should try to structure their visits to accommodate this need to speak to the patient privately and confidentially. Once the issue is recognized it is important to discuss it with everyone involved, and here again the physician can play a role in helping the different players in the situation understand that there is no blame involved but rather a misunderstanding that led to an unfortunate decision.
Had she berated her mother for not being a caring parent and grandparent, or made her feel guilty by saying that she had decided to go back to work based on knowing that Fatima would be looking after the infant, Fatima may have changed her mind, acquiesced, and then been resentful for many years to come. The result is likely to be fruitful and satisfying for everyone, with the possibility of Fatima expanding her free days or contracting them, depending on which of her activities gives her the most satisfaction.
Or she may continue with the same mix of time, thereby enjoying both her family and her own new achievements and personal growth. They were teenagers when they met in Warsaw, and both they and their families became very good friends. When the Nazis invaded their country, Moshe was twentyone and Miriam had just turned nineteen. Trapped, as were hundreds of thousands of other Jewish families, they tried to live their lives as normally as possible. What followed was almost five years of unimaginable personal terror and horror for each of them.
They watched in anguish and anger as family members and friends died before their eyes or simply vanished, never to be seen again. It was weeks after their camp had been liberated that Moshe and Miriam were reunited, both of them mentally and physically scarred. They slowly recovered their health, and once the emotional pain had subsided to a manageable level, Moshe and Miriam knew they had to get on with rebuilding their world, which was now empty of all their families and most of their friends.
Fortunately, Moshe had a cousin who lived in Montreal who sponsored them to come to Canada. Moshe and Miriam adjusted to their new world with remarkable agility. Thanks to some helping hands and their own sense of drive and purpose, the young couple soon had good entry-level jobs: Moshe learned the tool and die business while Miriam, who had a special skill with numbers, learned to be a bookkeeper in a small textile company.
They worked hard, saved money as they could, and forged ahead. In they bought a small house on the outskirts of the city, and a year later Miriam gave birth to their first child, a son they named Seth. Two years later she had another son, Isaac. Helen was born eighteen months later. As the years moved on, the Greenberg family remained very closeknit.
What is the Sandwich Generation?
Moshe took his sons to synagogue every Friday night and often talked to them about the importance of their heritage and the huge pains inflicted on their family and their people during the course of history, and especially during the past world war. Seth became a chartered accountant and landed a good job with a Toronto-based firm specializing in the lucrative field of forensic accounting.
Isaac, who had always loved music and was an accomplished pianist, studied business in university and ended up managing a number of rock groups, bands, and singers. Helen studied physiotherapy and started a small but successful clinic with three partners that grew into a real going concern. As the children moved ahead with their own lives, Moshe noted that Seth, Isaac, and Helen and their families spent less and less time with their parents, and they seemed to drift away from the strong religious grounding he and Miriam had instilled.
Several years ago, Moshe and Miriam moved into a retirement home that had an adjacent long-term nursing facility. They continued to live fairly independently, with daily support services. Their three children and their spouses and grandchildren visited regularly and phoned often to check on them and discuss their needs. Now, Moshe is eighty-two years old. His health has been steadily failing over the past five years. First, he was diagnosed as a diabetic. A year later, he suffered a mild heart attack that left him weakened and tentative because he was afraid of another, more severe, attack.
But instead of another heart attack, Moshe suffered a stroke, and then another. Since his second stroke, Moshe has been unable to speak or move his left arm or leg. Late last year, Moshe was transferred to the long-term nursing facility, while Miriam moved to a smaller apartment in the retirement home.
At eighty, Miriam is still vigorous and mentally alert. She visits her husband at least twice a day and sometimes sits with him for several hours at a time. Rabbi Rubinfeld was very clear and firm in his counsel to her: the sanctity of life is more important than any other factor, he told her. He said that was true in Judaism and every other religion, and that no matter what, every effort must always be made — with no exceptions — to keep any living being alive.
Miriam accepted his wisdom totally and told her children how she felt. What her children saw, though, was a father who was a shell of the man they knew and whose life was barely livable.
See a Problem?
But their mother made it clear that she was in charge of the situation, and that as long as she was of sound mind her first priority was to keep her husband alive. In what they thought might be a good step to take, Seth, Isaac, and Helen decided that Seth should meet with Rabbi Rubinfeld and ask for his support. Meanwhile, Moshe contracted pneumonia and required treatment with antibiotics and oxygen, but he recovered. But it was clear to the physicians and nurses that he contracted pneumonia because of the difficulty he has swallowing.
They felt that he would need a feeding tube to provide nourishment and fluids to maintain him and to reduce the risk of further episodes of pneumonia. The doctor at the nursing home asked Miriam what she would like to do. He said they could try feeding him again, but that if he developed another bout of pneumonia he could die from it. On the other hand, the feeding tube had some risks, although for the most part it was a fairly safe procedure.
The doctor also explained the situation to Seth when he came to check on his father. Seth called his sister and brother to tell them about the choice they had to make. On a different occasion two nurses spoke to Helen and said that Miriam was so devoted that even with a tube her father could still have some meaningful and comfortable life ahead of him.
Seth and Isaac told their mother that while they loved their father, watching him like this was very painful for them and they wondered if he would have wanted a feeding tube had he been able to make such a decision himself. They felt he would not. Miriam was furious.
She told Seth and Isaac that she felt they were betraying their father and their faith. She appealed to Helen for support. She reminded them of the terrible ordeal she and Moshe had experienced so many years ago and said that was evidence that one should never, ever give up on living. Now, there is a high level of tension between Seth, Isaac, and their mother, with Helen not quite sure if her mother is right in making this decision.
In the health care profession, we usually think of the conflict as being one in which a patient and family have 74 C ULTURE C LASH their own peculiar perspective which is not understood or shared by the health care team, thereby leading to unnecessary conflicts.
In fact, many health care organizations and health care professionals seek ways to get advice about and assistance with cultures they do not fully understand. In other cases, some health care team members might be so intent on allowing the patient to have the final say that they fail to recognize and appreciate that in a particular culture it is the accepted practice for the eldest son to make a decision and protect the parent from the pain associated with such a step.
All religious, cultural, and ethnic groups have beliefs and rituals with special meaning and importance to those who follow the tenets of the particular group involved. It is important for health care providers to understand where decisions come from so that they can best support the decision-makers. In this particular case, the problem appears to be an estrangement of underlying values between Miriam and at least two of her children, coupled with different health care team members providing conflicting advice to family members.
It is often the case that different generations with different life experiences have incongruent value systems when facing difficult end-of-life situations. As for the staff, they should not be providing advice based on their own personal values to a family in turmoil. Rather, they should limit their advice to the factual level of whether feeding tubes could safely provide nourishment to Moshe and decrease the risk of aspiration pneumonia. What is the best way to support this family and do everything possible to help them through a difficult period so that after Moshe dies they will still be a loving and caring family?
From their past actions, it is clear that Miriam and Moshe take pride in their Judaism and have expressed a commitment to follow its tenets. For Miriam, the concept of sanctity of life is very important, and its importance was emphasized to her by the rabbi she consulted. He also would have told her that providing food is an obligation except when doing so itself causes harm, and so giving Moshe a feeding tube would be an extension of that obligation to feed.
If Moshe was not likely to survive the pneumonia and was in fact dying, the rabbi might very well have given different advice to Miriam. For most religious Jews, the obligations concerning the care of a dying person are different; comfort becomes paramount, so a feeding tube might not be inserted. For Miriam, it is clear that the religious rules and obligations are important to her husband, as they are to her.
She would likely take great comfort after Moshe dies knowing that she assured his care was in the religious tradition of Judaism, even if the outcome was not what she wanted. If, on the other hand, she were to ignore what she believed his wishes would be, she would likely carry the guilt with her for the rest of her life and blame herself for not doing the right thing.
The children, who are no longer committed to Jewish tradition and law known as Halacha , may fail to appreciate that certain rules exist that may not make sense to them in a secular world. Similar value systems are shared by Muslims and many of the Catholic faith. On the other hand, people from Southeast Asia may approach the same situation differently from someone from South America and still differently from someone from the Caribbean.
Seth and Isaac may have difficulty understanding why Miriam is so intent on trying to keep their father alive when he appears to have such a poor quality of life. It might be worthwhile for Seth and Isaac, if they have forgotten the basic tenets of Judaism when it comes to decisions such as these, to meet with the rabbi privately for an explanation of the basis of the decision.
Even if they long ago abandoned their own Jewish religious beliefs, they are likely able to project sufficiently to understand the basic underpinnings of the faith and how it affects decisions. For families in which the value-based ties have been splintered, it is important that the children step back a bit and try to imagine the values of their parents. By doing this, they should be able to understand the importance of following through in the practice of the religion or culture that they hold.
Many people who appear to have abandoned their religion during their adult years find comfort in the traditions and practices as they approach death. There is nothing inconsistent or hypocritical in this shift, and everything should be done to support people who need to revert to previously held beliefs, even those they may have ignored for years, if that is what makes them comfortable during their remaining days.
Seth, Isaac, and Helen should try to find a way to gather around Miriam and tell her that whatever decision she makes is the right one and that they understand the Judaic reasons for the decision and support her in that difficult choice. If Moshe lives for many months, even if he does not improve at all, they must not waver in their support of her decision.
It is especially dangerous if drugs and alcohol are mixed, which can lead to dire consequences and to huge concerns for the children. Gilles was a construction worker from the time he left school when he was seventeen until he retired at age sixty-six. He always liked to have a few beers with his buddies at the end of the day, followed by several shots of whiskey in the evenings after dinner.
They were very close and her death was a terrible blow for Gilles. He retreated into his house, and further into himself, for several years. And he drank more, although he denied it to his twin fifty-two-year-old daughters, Eva and Estelle. Two years ago, Gilles was in a minor car accident late one night and was charged with impaired driving. His licence was suspended, and although he can now reapply for a licence, he has not done so. She visits her father once a week for an hour or two, but because she often finds him tipsy, argumentative, and moody, she rarely enjoys the visits.
Eva lives in Montreal with her second husband; they have no children and are financially secure, which in their case means they often enjoy travelling to distant destinations for several weeks at a time. About a year ago, Gilles met and became friends with Claudia, a widow who is ten years younger than Gilles and lives in a nearby apartment building. Claudia now spends most of her time with Gilles at his home.
In fact, they believe Gilles gives Claudia money to buy his beer and whiskey. They also find that Claudia is not particularly open or friendly with either of them, and she usually defends Gilles in any discussion about his lifestyle or drinking. As worrisome to the daughters, they believe that their father is lavishing gifts on Claudia, and that Claudia is under the misguided impression that, despite his meagre lifestyle, Gilles has a lot of money.
This, of course, results in his being inebriated most of the time. And recently Estelle discovered that her father is also taking tranquilizers prescribed by his doctor. The doctor acknowledged that he knew Gilles was an occasional drinker but not that he drank as much as Estelle claimed. Estelle then called Eva, and the two of them went to visit their father. They confronted him about the drinking, but he denied that he drank too much and was very defensive.
They also told him that they were worried about what to them appeared to be memory lapses and poor judgment during recent visits and telephone calls, and they wondered if mixing the liquor with the tranquilizers was wreaking havoc on his mind and body. If anything, they told their father, he seemed more depressed than ever. He got quite angry and told them that his life was much better now that Claudia was part of it, how she looked after him with much more care and attention than his own daughters, and how much that meant to him. They would both benefit, their father explained, because Gilles would always have someone around, and Claudia would be able to save the money she paid for her apartment.
It was at this point in their heated exchange that Claudia arrived, and a strained, polite, and inconsequential conversation followed before Estelle and Eva left. The sisters both went home. Later that night they had a long telephone debate about what to do and how to do it. The more Eva and Estelle talked, the more other fears surfaced, like the thought that Claudia would somehow manipulate their father into assigning ownership of the house to her, or talk him into giving her power of attorney and then having him institutionalized, selling the house, and walking away with what was left of his modest savings.
They should have many concerns, the first being the psychological and physical well-being of their father. Gilles is on a path to the almost certain severe consequences that result from consuming excessive alcohol combined with tranquilizers.