the olds

7 posts

A Guide for How to Age Gracefully

We all are getting older each day we roam this earth. Some of us faster than others. Some of us encounter, health issues beyond our control and some of us will face tragedies that will tax our emotional well-being. However, if we can avoid those misfortunes, many of us can find ways to age gracefully, healthfully and energetically. For those of you that have faced misfortune, we prayerfully stand next to you. Please take this post in jest.

I was always a naturally thin person that could eat a double scoop of ice cream cone at 1 AM without a second thought. My mother is 62 and looks 40. At the exact age of 41, said ice cream cone went straight to my ass and under my chin. I didn’t bounce back from a night of balls-to-the-wall drinking at age 35. And most recently, eating sushi puts bags under my eyes. Riding the motorcycle makes my joints ache. Continue reading

Good God. This is the Scariest Photo You’ll See All Day

Joe Biden, or Uncle Gaffey as some of us like to call him, is known for his congenial nature; his ability to mingle with the regular folk, sip a beer, riff with the working man about his life in Scranton, PA, while getting real up close and comfortable. He likes to have your undivided attention when he’s sharing all his stories. Anything less, apparently, just won’t do. Well, this all may be a little too much for one senior citizen. Behold. Continue reading

No One Here Gets Out Alive: The Thrilling Conclusion

In Part One, we examined the need for choosing a Health Care Proxy and making decisions about your Advanced Directives. In Part Two, we examined the realities about CPR and artificial nutrition.  Those are the big decisions that you need to make, but there are other things you may want to consider and put in your Advanced Directives/Living Will.

Hospital Transfers (Do Not Hospitalize order): If you are in a nursing home or even receiving treatment at home, you or your HCP can request a Do Not Hospitalize (DNH) order which is basically what it says.  If you  were to become acutely ill, you would not be sent to the Emergency Room  for evaluation and treatment, but be treated where you are, non-aggressively.  Hospitals can be a crappy place to spend your last hours.  Busy, noisy and intrusive not to mention frightening to someone with dementia or really anyone in crisis.  Hospitals are not the place for a peaceful death – if that is your goal.  However, without an explicit order, it’s possible that you may get sent in by a skittish provider who is not familiar with you or your wishes.

No Diagnostics or Treatment: You can also ask to have no diagnostic work – blood work, x-rays etc.  And request not to be treated for such common ailments as a urinary tract infection or respiratory infection.  You may decline surgery, dialysis, blood transfusions and medications.

Organ Donation: Please, please, please be an organ donor.  Let your family know of your decision and register as an organ donor. Even if you or your loved one has been sick for a while, they may still be eligible to donate skin, tissue or corneas.  There is a myth that if you register as an organ donor, the ER staff will not work as hard to save you.  Nothing could be farther from the truth.  ER doctors and nurses live to save lives.  It’s what they do, it’s who they are.  Trauma unit staff take it personally if they can’t save you.  It’s all they think about.  They are not going to let you die if there is a single thing they can do about it.  So please don’t not register because of this urban legend.

There are always going to be situations that don’t fit into the categories we have discussed.  Again, I will recommend Five Wishes.  This tool helps you think about life and death and what you priorities are.  You can also use it to think about what a loved one may have wanted, if they haven’t expressed their wishes beforehand.

Nothing is harder than to have to make these decisions for someone you love.  Please try to talk about this with you loved ones.  Even if you can’t talk about it directly, try to understand and appreciate what makes life worth living for them, what their spiritual beliefs are so you can make the best decisions should you ever be in that position.  And always remember it’s about the person who is sick, not about you.  What would they have wanted?  How would they want to live or die?  What was important to them?

For anyone who is going through, or has gone through this, you have my deepest sympathy.  I hope you are able to find peace and feel that you have done the best for your loved one.

As promised, an excerpt from my own advanced directives:

In the event that I

a)     Am in a terminal condition caused by illness or injury and have no reasonable hope of recovery or becoming aware of my surrounding or being able to use my mental abilities and/or;

b)    Have a progressive illness which will continue to worsen and result in my death and which cannot be improved or cured –including, but not limited to, progressive neurological diseases including, but not limited to: Alzheimer’s, Parkinson’s, ALS, MS, or any form of dementia and/or;

c)     Have any condition that makes me unable to recognize people or to speak understandably and this condition is permanent and cannot be improved or cured, but is not considered in and of itself to be terminal, including, but not limited to, a persistent vegetative state, coma, severe stroke, injury or the progressive neurological diseases or dementias listed above, my wishes regarding medical intervention are the following:

No resuscitation (no manual, electrical or chemical cardiac resuscitation)

No intubation or any form of respiratory support (see below re: oxygen

No dialysis, no blood transfusions

No surgery for any reason or condition

No oral or IV/IM antibiotics or any other medications given with the intent of saving or prolonging my life.  Any underling medical conditions such as (but not limited to) diabetes, hypertension, DVT should not be treated, nor do I wish to be treated for any acute illnesses including (but not limited to) urinary tract infection or respiratory infection.

No artificial or supplemental nutrition or hydration in any form or via any mode of delivery.

No diagnostic testing or monitoring whatsoever.  No blood work, no imaging nor any other test invasive or non-invasive to diagnose any illness or condition.

If I am in a skilled nursing facility, sub-acute or rehab hospital, no transfers to any acute care hospital or emergency department for care or evaluation under any circumstance.

I DO, however, wish to be given any medication, including, but not limited to, narcotic and/or non-narcotic pain relievers, benzodiazepines, anticonvulsants or similar medications IF the sole purpose is to decrease pain and/or increase comfort. As a nurse, I fully understand that these medications often, when used in amounts necessary to fully ease suffering, may hasten or even cause my death.  I also authorize the use of oxygen so long as it is being used for comfort measures and not for prolongation of life.

No One Here Gets Out Alive Part 2: DNR and Artificial Nutrition

In Part One of our series, we all accepted the inevitable and subsequently gave serious thought to who we would choose to make decisions for us were we unable to do so.   Nah.  I know we’re all still in denial.  That’s why I plan to keep nagging you all by talking about this with some frequency.  Today we will talk a bit about some of the actual decisions you need to make for yourself, and possibly for a loved one.  Because I would like to not overwhelm you with information and give you enough information, I will break this down a couple of issues at a time.  Today we will discuss the two biggies:  Do Not Resuscitate orders and artificial nutrition.

DNR stands for ‘Do Not Resuscitate’.  What this means is that if your heart stops beating and you stop breathing, your medical and nursing providers will not attempt CPR or any other means of restarting your heart or breathing.  When making this decision it is important to be realistic about the limits and success of CPR.  TV representations of CPR are very unrealistic, with survival rates over double that of real life.  Also, contrary to what you may see on TV, people don’t get up and walk around after being resuscitated.  They spend days, maybe weeks, in an Intensive Care Unit on ventilation and, if they survive long enough to be discharged, a rate that has been described as being close to zero,  there is often residual physical and cognitive damage and months of rehabilitation that follows.

CPR survival rates range wildly and are affected by how sick you were in the first place.  Generally speaking, 3-37% of people outside of a hospital who get CPR survive the initial resuscitation.  It’s 3-15% for in hospital attempts, reflecting the poor outcomes for people who are already sick or elderly.  Again, this is ‘survival’ of the resuscitation attempt only.  As an historical side note, it has been noted that CPR survival rates have gone down since its introduction because it is used so often on people who are not appropriate candidates (people too sick or of an advanced age to survive)

The best candidates for CPR are younger, generally healthy, victims of trauma or who have a sudden cardiac arrest caused by an arrhythmia.

If you are making this decision for an elderly family member, the simple, honest truth is that they will not survive the attempt.  And even if they do, they will never get out of the ICU.  That is the blunt and honest truth.  Even more ‘Dr. House’:  we will do nothing but crack their ribs into pieces and disrespect their death by attempting it.

DNI: Do not intubate.  This generally goes along with a DNR.  I have seem some orders that are DNI only which is utterly nonsensical as you will need to be intubated if you stop breathing and your heart stops.  Why do CPR with all its intendant risks if you’re not going to follow it up with respiratory support?

Artificial Nutrition:  Artificial nutrition most often takes the form of tube feedings.  This is a tube that is surgically inserted into your stomach or intestine and a liquid supplement is infused directly in.  There are several indications for this, and it is not necessarily an end of life procedure.  For example, Roger Ebert has a gastric tube as a result of his cancer and surgery.  Anyone who loses their ability to swallow is a candidate.  People with esophageal or gastric cancer or people who have neurological swallowing issues because of a stroke are just a couple of examples.  Most of these people live perfectly fine lives with a feeding tube.  However, if you are in a persistent vegetative state or end stage dementia or end stage neurological disease, it is a different kind of decision.  You will have to think about how you would feel having this is there was no hope of recovery or returning to your previous mental state.   Many people with dementia lose their appetite as well as the ability to coordinate their chewing and swallowing which puts them at risk for aspiration and pneumonia.  A feeding tube is often recommended in this situation.  A feeding tube will only provide nutrition.  It will not cure or reverse the natural processes that are occurring.  The same is true of IV hydration.  As people lose the ability to swallow, they become dehydrated and the kidneys and body shuts down.  Fluids may be administered, but will only delay the inevitable.

It is important to note that it is not ‘starving’ someone if artificial nutrition or hydration is declined.  Any pain at end of life would be managed aggressively and comfort and dignity are the paramount goals.  In addition, the dehydration that naturally occurs results in electrolyte imbalances that cloud pain and cognition and provide a natural pain killer and release of endorphins.

I think that’s enough for today, kids.  If you want some help thinking about these decisions, there is an excellent resource called 5 Wishes that helps you think through these end of life decisions.  In the next installment, I will discuss dialysis, Do Not Hospitalize orders and organ donation – and the exciting unveiling of my own advance directives – Spoiler Alert! – Don’t keep me alive.

The awesome story behind the thumbnail pic.

People in the Neighborhood: Bodega Edition

New Yorkers always insist that the city is not an anonymous machine but actually just a series of small neighborhoods.  We insist that we know our dry cleaner, our coffee shop guy, our grocery store cashier just as well as you all know yours.

Actually, that’s not true, we always insist that we know them even better.

Actually, that’s not true either.  We New Yorkers are a narcissistic bunch.  We insist that they know us even better.  Trust me, your local dry cleaner does not care about you the same way my dry cleaner cares about me.

In any event, when I have lived in other places, one of the reasons you knew the “kid who bags your groceries” is because of some long generational history.  The gossip you discuss as you head back to your car is along the lines of “Oh you know, that’s Johnny’s nephew.  His momma went to school with…”  Etc.  Well no, we don’t have as much of that in Manhattan (although it is more common in the other boroughs).  Our stories are a little bit different.

And I think it’s only fair that those of you who are not from a big city filled with people from all over the world be introduced to what some of our neighborhood knowledge looks like, and the center of it all is the local bodega.*

*Details have been changed to protect the innocent.  Also, no, I do not actually believe that any of this is unique to New York.  I promise.  Okay, maybe a little bit.  Nah, not really.


The Turtle Era

The Turtle Era was the best era.  Turtle was the Day Manager when I first moved into my neighborhood.  His first language was Spanish, and he spoke perfect English.  He insisted that I only use Spanish and that he only use English.  Because, you know, that’s how you improve. But he had also learned Korean, the language of the store’s owners, and Portuguese, because there was small Brazilian community in the neighborhood.  The store was always perfectly kept while he was in charge.  Well-stocked, clean.  And the coffee.  Dear god the coffee he made was perfect.  He was funny, charming, handsome, confident, told a great story.  I really wanted to drink with Turtle.  All the time.  The owner’s wife was confused about his name and called him Tut.  Which stuck.  About half of the customers called him Turtle, and about half called him Tut.

Turtle’s assistant was named Nick.  Nick was quiet but polite.  He was never completely happy with the questionable wage and hour policies of the owners, but you wouldn’t have known it.  One of the nicest men I’ve ever known, with a genuine smile and a kick-ass mustache.

The night shift during The Turtle Era was run by a quirky older guy from rural somewhere.  I don’t know where he was from, or what language he spoke, but he was differently from the country of some country. (You know how you can sometimes tell a rural accent even if you don’t know the language?)  I was never sure what we were talking about when I went in, but I think we were talking about something. I don’t know what his name was.  I’m not even sure how I could have asked. His assistant was a quiet guy from the pacific coast of Mexico.  I don’t think I’ve ever heard him say more than two words.  In fact, sometimes I didn’t even know he was there and then “POOF!” he’d be standing right behind you.  Basically a not-very-haunting ghost of a man.  You will not hear about him again because that is all I know, even though he is still there.

Turtle was lucky.  He married for immigration status, or so it was implied, but he fell in love.  They had an adorable little girl.  His wife, a midtown professional, got a promotion that took her to New Jersey.  He went with her, and they bought a big house for the family.  Last I heard he was managing a restaurant out there and going crazy because he had never needed to drive before, and he didn’t have his driver’s license yet.  But he was happy.

The Nick Era

Poor Nick.  When he took over for Turtle, they didn’t hire a new assistant.  So Nick had to do everything.  And I don’t think they gave him a raise, not at first.  But we gave him a quick primer on New York labor laws and how they did, in fact, apply to everybody.  And then they did.  He was so politely sad about it all. He would politely ask me what it was like to have a good job.  He would listen to traditional music and count the hours until he could go home and rest and have a beer. He was sending money home to his wife, where she ran a farm.  Each paycheck went to building up the livestock, building a fence, fixing a barn.  Nick spoke a little English, and I speak a little Spanish.  Between the two of us, we could figure it all out.  Nick also had taken steps to learn how to make coffee from Turtle before he left.  God I miss Turtle’s coffee.

Then someone called in a Housing Violation on his building, and the city discovered his illegal apartment. We offered him a little help to find a new place, but he politely refused. Before they could shut it down he discovered he had cancer.  He decided that it would be best if he went back home.  If he could get medical help, he could get it safely at home.  If he could not, then he wanted to spend his remaining days on the farm with his wife.  He knew that either way, once he crossed the southern border, he would likely never come back.  No one has heard from Nick since he was getting a ride south from Atlanta with a friend.

The night shift did not change during The Nick Era, but I got to know the Country Man a little better.  I still don’t know what we were talking about, but we talked a lot.  When the store raised the prices on cigarettes he made a disgruntled face and refused to charge me the new price.  He would always round my charges, refusing my fifteen cents here or my seven cents there.  Either he was overcharging someone else or the owners just liked him, because he certainly wasn’t paying it out of his paycheck.

The Son Era

Good kid.  Friendly, happy, got good grades, played in a soccer league on the weekends.  New York Mets fan, but nobody’s perfect.  The son had come in on occasion to fill in as necessary, but once Nick left, he took over the day shift.  He had recently finished college and was applying to graduate schools.  He insisted on calling me by my last name, which freaked me out.  No matter how many times I tried to get him to stop, he couldn’t seem to do so.  “Are you watching the game today Mr. LeSabre?  Should be a great one!”  During his tenure they hired a new assistant, a really young kid, Johnny, who spoke only Spanish at first.  Johnny practiced his English like crazy.  He would step behind the counter as often as possible and come up with the most unnecessarily complicated questions he could.  Just to practice.   Johnny seemed to believe that my life consisted solely of making a lot of money, going out on wild dates, and drinking as much as possible.  He had no evidence for any of this.

Johnny met a girl that lived in another borough, and two weeks later he quit.  A cousin of the son was hired to replace him, and he is still there.  I think the cousin is confused about his job responsibilities.  He seems to think he is a security guard at a bank because all he does is stand about three feet from the counter like a statue.  No one seems comfortable telling him otherwise.  Much dust has accumulated since the cousin started.

The Dad Era

And now we are in the Dad era.  The son has gone back to school, and I’m stuck with grumpy under-paying, shitty-coffee-making dad.  If you buy cigarettes, he won’t give you matches unless you ask.  If you buy coffee, you have to ask for the napkin.  God forbid you ask for a sleeve.  You’d think you just tried to shake down the ATM machine.  And he never smiles.  He is a mean old man.  (Sometimes he forces a smile, but you know that forced smiles are worse than no smile at all.)  But I don’t really mind.  We have our routine.

The older son is there on occasion too now.  A character and a half.  I appreciate that he does not care even a little bit.  He would rather sit outside and smoke or rush home to his (admittedly gorgeous) new wife.  Since Turtle left, he’s by far the person I’m most inclined to just hang out with for a bit.  Because he smokes.  And because he will inevitably go on some rant about something in the pop culture news.  (He’s like a particularly incensed Crasstalk commenter now that I think about it.)

And recently, Country Man has gone from the night shift.  His wife, back in the old country, has become terminally ill.  He hasn’t seen her in years and wants to spend her last few months with her.  He may come back when she passes away, but maybe not.  I hope he does.  I miss Country Man.  Country Man’s replacement unintentionally sold cigarettes to minors on multiple occasions and got the store shut down for a week.  The doors were locked for the first time in thirty years.  They didn’t even know where the keys were.

The jarring feeling the next day when I went to buy my morning coffee, when, distracted by my email, I ran straight into a closed door and a big ol’ New York City notice, made me realize just how much a part of my life the little store on the corner is.  Good or bad, happy or sad, it’s a part of my life, and a part of what keeps the city from feeling so anonymous.  I’m no fool; I don’t pretend we are friends or even colleagues.  But I know them, and they know me.

Images from here.