The Thantorium & Santa Monica

 

https://www.alz.org/careplanning/downloads/lawton-iadl.pdf

 

I am seeing Beverly because the nurse is asking for my help. She tells me she thinks Beverly might be delirious, have dementia, or be depressed because Beverly is saying she wants to die. For the nurse, this is a clear sign of disturbed thinking.

So here I am with Beverly and first I ask her to tell me the months of the year backward and what would she do first if her house was on fire. Beverly tells me the months of the year backward and that she would call 911 and leave the apartment: her thinking is clear, she is not delirious. I ask her to remember three words and draw a clock with all the numbers and the time set to ten minutes past eleven, all of which she does just fine. Beverly is not demented. Beverly is worried.

She has been asking her daughters for more help for the last two years as living on her own has gotten harder. Her daughters live in homes with no extra space and too many stairs and they wanted her to stay in her single-floor home and be independent. But there is only so much time and so little money. There are only so many caregivers available for Beverly and all the older adults who need more assistance. Her family, like so many others, are doing their very best.

WHAT IS THE SILVER TSUNAMI? “As the baby boomers reach their senior years and as longevity increases, there will be a groundswell of seniors. “The Silver Tsunami” is a metaphor used to describe the expected increase in the senior population. Today 15% of Americans are 65 or older. That number is expected to balloon to over 20% by 2050, bringing an estimated 40 million additional people relying on Medicare, using the healthcare system, and seeking senior living. https://www.leisurecare.com/resources/silver-tsunami-senior-living/

 

Through no one’s fault, Beverly is now lying in a hospital bed on the tenth floor with a lumbar fracture and there is no fixing the fact that she is permanently unable to walk and incontinent of bladder and bowel. She needs to be cleaned in a timely manner around the clock and repositioned every two hours while she is either in a bed or a chair, which will be always. Even with perfect care, she will eventually develop pressure ulcers, then pneumonia or sepsis and eventually death. That will happen in about a year, or two, or four. Beverly is very aware of what awaits her.

“I couldn’t live like that,” you say, sitting back in your recliner. As if that is a choice Mom!

Besides, Beverly feels the same way, and so she is asking herself what seems to her a reasonable question:

“Can’t I just die now instead of going through all that?” she says.

“You mean Death with Dignity?” I reply.

“Yeah, that. Can you help me?” she repeats.

What Beverly is requesting is an End of Life Option, but I already know she won’t qualify. The statutes that allow a patient to choose death with a self-administered prescription are only for adults who have a terminal illness with a confirmed prognosis of six or fewer months to live. This option is only available in ten states but we are in California which is one of them. However, Beverly’s current condition does not qualify her for help in ending her life, not with her interminable illness. It’s her life, but not her terms.

Despite knowing this, I tell Beverly I will talk to her team and convey that she has expressed the desire not to live any longer given her new level of disability and what she deems to be a quality of life not worth living.

I let the in-patient hospitalist and her regular clinic doctor know. Her primary care doctor states that Beverly is depressed and has been refusing antidepressants for the last year as her situation declined and she was asking for more help from her daughters. The psychiatry team tells me that they are trained to differentiate between suicidal ideation stemming from depression versus a reasonable desire to die given a poor trajectory. I know that even if this conversation and evaluation happen, Beverly is being discharged to a skilled nursing facility because the level of her care exceeds her family’s ability to provide it. From there she will have little opportunity to follow up with her regular doctor or a psychiatrist. The best she can hope for is to lose enough weight to qualify for hospice, and maybe her family would let her die at “home”, i.e. one of their houses.

I round with psychiatry three mornings a week on their patients over sixty-five years old. Today we are seeing Thelma, a ninety-year-old woman we are holding on the medical floor on a 5150 after her unsuccessful suicide attempt. She is an amazingly sweet woman, polite and thankful; embarrassed to have caused us inconvenience. Two days ago she was in ICU and intubated. Today I am trying to convince the busy bedside nurse that Thelma can get up to go to the bathroom or at least the bedside commode and not use “the pee sucker”. A Purewick is like a female condom catheter, it takes the pee away...it also trains patients to get used to peeing in bed, to become incontinent. <An older adult loses five percent of their muscle mass for every day they stay in that hospital bed instead of walking around.>

“That’s disgusting and dehumanizing!” you say, flipping through the New Yorker looking for that cartoon about cats. Yeah Mom, but here’s a math problem for you: How long does it take two patient care techs to mobilize twenty-four sick people three times every day?

Thelma took forty-one opioid pills she had been hoarding for years, planning for this day. Recently everything has just become too much for Thelma. She fell and broke an ankle two years ago. It took her three months to recover. Terrified that another fall could result in a more serious injury similar to Beverly’s, Thelma now limits her movements to one floor of her house. She no longer ventures outside and she has limited her showering to a few times a month to avoid slipping in the tub. Just in the past year, she lost her two best friends. Then two months ago the daughter of one of those friends, Thelma’s godchild and “back up”, also died. So she took the pills, was found by her husband, and woke up at the hospital.

“Why can’t Beverly and Thelma just die when they want?” you ask, plucking the dead heads off the marigolds. I don’t know Mom, I guess the Puritans didn’t grow up with icebergs?

Looking for Where to Retire? Skip the Income Tax Breaks, the Low Housing Costs, the Beaches and the Nightclub Hot Spots. Consider these states instead: ●     California (End of Life Option Act; approved in 2015, in effect from 2016) ●     Colorado (End of Life Options Act; 2016) ●     District of Columbia (D.C. Death with Dignity Act; 2016/2017) ●     Hawaii (Our Care, Our Choice Act; 2018/2019) ●     Maine (Death with Dignity Act; 2019) ●     New Jersey (Aid in Dying for the Terminally Ill Act; 2019) ●     New Mexico (Elizabeth Whitefield End of Life Options Act; 2021) ●     Oregon (Death with Dignity Act; 1994/1997) ●     Vermont (Patient Choice and Control at the End of Life Act; 2013) ●     Washington (Death with Dignity Act; 2008)

 

“What’s the most non-conformist act you can commit as a human being?” I ask him.

“Choosing not to be alive anymore.” He answers.

For those of us surviving suicide, we know the damage done, and why Beverly’s request is so anguishing, anguishing enough that we deny her. Our own tenuous grip on giving a fuck is questioned each time someone we love ends their life. “Why did you leave me in this shit alone if you couldn’t even handle it?  Thanks a lot!” Suicide plays on our sense of not being reason enough to stay, it feels selfish. Suicide dances on the grave, giving us the biggest middle finger ever. It is the last word.

But can we admit that there might be situations that deserve consideration?

Fifty-two-year-old man, alcoholic, unemployed, raising four children, depressed. Hung himself in the garage, found by his wife. <NO! No no no no no! We are going to get you counseling. We are going to get you financial support, get you sober, find you a job... Wait, we are aren’t we?>

Eighty-four-year-old Florida man with lung cancer metastatic to the bones, less than six months to live. Gunshot to the head next to the dumpster behind the shopping mall, found by his wife.

“The U.S. needs to get over their religious bullshit and change the laws so people can die when and how they want to,” you say while you look over the lunch menu. Yeah Mom, that. And meanwhile, could you maybe cut the jokes about me killing you?