Tuesday, 8 January 2013

Elderly care and the lives we lead

John Ashton says we are betraying a generation (http://goo.gl/awpwQ). He is right. But we don't need to appeal to the achievements of their generation to justify the assertions that he makes. Our commitment to the elderly does not really need to be qualified or inspired by their efforts in the Second World War, or their creation of the welfare state that we now take for granted. Those are all noble achievements. But our commitment to them should be implicit in the responsibilities of being members of a liberal, progressive and affluent society. We should offer them our commitment because we can, and because they need it. I don't know if we should be ashamed, but we should certainly be embarrassed at the care we offer the elderly at the moment.This embarrassment needs no context, or qualification - it stands alone as the reason for change.

The reality of the world that we create for our elderly and vulnerable needs addressing - care standards are often poor, and the elderly are socially isolated and achingly lonely. We offer them precious little succour, affection or worth, and we exclude them from our day to day lives. We are often blissfully unaware of how poorly looked after they are, and we are blissfully unaware that we are cementing a model of care for when we are ourselves elderly.

We never imagine that we will be the people who end up frail, alone and unloved. We find it difficult to foresee a future in which basic care needs are out of reach, and in which our own sense of self-worth is dependent on the actions that others take on our behalf. The disconnect between us now, and in our old age is completed by the disconnect between us today, and the legions of unnoticed, and uncared for elders, who sit quietly behind closed doors, hoping that something better might happen to them.

As we wander through the world, making choices about where to visit, who to see and what to buy, we cannot imagine that there will be a time when we do not have the fitness, the money or the ability to continue to do all of those things. We cannot understand that the world in which we swim so freely today will probably leave us behind, and that our habits and preferences will appear quirky and old-fashioned. We do not see that there is a cost for the opportunities we have as individuals. We are scattered on the winds, chasing adventure, fulfillment and wealth, and it feels rewarding. Yet the price can be high - our families are fractured and disparate, and our implicit support networks vulnerable. Perhaps we have higher levels of self-sufficiency these days, but perhaps we have overstretched the supply lines that keep us safe. Perhaps the knowledge that back home there is someone who loves us gives us strength, but perhaps it is illusory: perhaps love needs to be experienced, not assumed.

I have a baby girl. I think she is gorgeous (she is) and want to show her off. Quite often, I will show my patients a picture of her.  Sometimes it feels as if that action alone affords them more therapeutic gain that any of the medicine I offer them. Sometimes, I wonder what it would be like to do my ward round, carrying her with me. There is something visceral and spontaneous about the reaction a patient with dementia gives you when they see a picture of a beautiful baby.

I am often struck at how happy a picture can make them, and also at how detached it can make them seem. Pictures of babies are brief glimpses into a world from which they are excluded. And the flip side is also true: the elderly are a world with which children and grown ups are unfamiliar.
We are uncomfortable talking about dying, and we pretend it doesn't happen. We distance ourselves from reminders about dying. We don't spend enough time thinking about our own mortality and this is reflected in the way that we treat the elderly. Being elderly is often much more like being a child than an adult: it is a return to a phase on life when the support of others is crucial - they don't need isolation, they need company and support.

There is a complex interweaving of religion, community and individual identity in all of this, but there are some basic themes: familiarity creates comfort, practice makes perfect. We don't just need to spend more time with the elderly, we need to better understand their role in society.
That great sage of Northfields, @tobyhillman introduced me to some work done by a Franciscan monk, Richard Ruhr, who identified that throughout the world's varied and diverse initiation ceremonies, a few distinct home truths tended to be emphasised:
  1. Life is hard
  2. You are going to die
  3. You are not that important
  4. You are not in control
  5. Your life is not about you.
 
There is a bluntness to these themes that I don't like. But there is something in there for us: perhaps it is fair to frame it slightly differently: life is not about us, it is about the people around us, and the kind of impact we have on them. And life is more of a circle than a straight line: if we are lucky enough to live long lives, we are likely to end up near where we started out, and perhaps we should think about this when we make the big choices.