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Listen Between the Lines


 

When an elderly person is admitted to the hospital, Adrienne Green, MD, sees an opportunity for something beyond addressing the medical issues at hand.

“One of the key issues that is important for practical, everyday care is trying to figure out how the elderly are not functioning well at home,” says Dr. Green, an associate clinical professor of medicine at the University of California at San Francisco and a member of UCSF’s hospitalist group. “I think we do a great job of managing their diseases, but what we don’t do very well is helping them out with other things [such as coping with] their losses and the fact that they may be just barely hanging on at home in terms of their ability to care for themselves; and this hospitalization may really have set them back.”

Eva Chittenden, MD, an assistant clinical professor of medicine, also at UCSF, agrees. “Many hospitalists are so focused on the hospital that they’re not thinking about the ‘before the hospital’ and the ‘after the hospital,’” she says.

But after identifying the challenges that elderly patients face, communication itself may be challenging. Elderly individuals struggle with issues of control and allowing people to tell them what they need to change in their lives may not be an easy task. What are the best ways to communicate with hospitalized elderly patients to facilitate the best “whole-person” care?

When you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick, it’s important to remember that there will probably be no other state that they’ll be in … where they will feel so out of control.

—David Solie, MS, PA

Under the Radar Screen

The hospitalists interviewed for this article agreed that getting a broader picture of an elderly patient’s health and well-being involves discovering how they are really doing at home. Dr. Green asks simple questions, particularly about activities of daily living, such as whether they’re doing their own shopping and cooking. She also involves the family, “because very frequently the patient will say, ‘I’m doing fine,’ and the family member is in the background shaking their head.”

She also looks for clues about whether the patient needs more help at home, whether they are compliant with their medications, and if not, why (e.g., can they open their medicine bottles)?

“I frequently have the elderly patients evaluated for home care just to get someone into their house … ,” says Dr. Green. “I think that probably 80% of our patients who are over 80 who come into the hospital have things in their homes that are not safe, such as throw rugs.” Even if patients are basically doing OK, “if I can get some home care for them, I know we’ll uncover a ton [of things that can be improved],” she says. “These patients may have … kind of snuck under the radar screen of their families and their primary [care physician], and I think the hospitalization kind of opens that up in some ways.”

Facing Resistance

Even if issues are uncovered by means of interviews and home-health visits, however, many elderly patients present a particular communication challenge. This, says David Solie, MS, PA, author of How to Say It to Seniors: Closing the Communication Gap with Our Elders, is because of the difference in circumstances and current experiences between the elderly and their hospitalist providers.1 It is common knowledge that younger people go through stages of development, but the elderly do, too, says Solie, who is medical director and CEO of Second Opinion Insurance Services in Woodland Hills, Calif., a brokerage that specializes in the insurance needs of impaired-risk, elderly individuals.

The last human developmental stage compels elderly adults to work hard at maintaining control over their lives in the face of almost daily losses. A big part of the losses they experience involve their health and functioning, and the ways different patients cope with loss and the perceived stresses of healthcare have been analyzed and categorized.2-5

But in addition to loss of control, the elderly also face the daunting task of discovering what their legacy will be—what will live on after they die. “The way our elders communicate contains clues to the urgency they feel in trying to resolve these items on their agendas,” writes Solie. “In almost every conversation with older adults, control and legacy issues rise to the surface.”

Connect with Legacy Issues

A change in an elder’s circumstances can intensify the legacy-search process.

Ask open-ended core questions to connect with what they might be thinking and feeling. Examples are those that may be related to healthcare issues or that will help elicit relatedness, which will then facilitate decision-making:1

  • What was the world like when you grew up?
  • In what ways are you like your mother?
  • In what ways are you like your father?
  • What was the most significant event of your childhood?
  • What were your family’s greatest strengths?
  • In what ways do [did] you and your spouse complement each other?
  • What has been the happiest time of your life?
  • What are you most thankful for?

Begin statements with “Tell me about … .”Remember that the loss of health can change everything, and the move from being young-old to old-old gives a new urgency to the life review. Listen for statements that reflect this, such as:

  • “I guess that’s the last time I’ll be able to make that trip to the lake.”

    You could respond: When did you make your first trip to the lake? Who were you with?

  • “I am not sure how many more birthdays I’ll be around to celebrate.”

    You could respond: What was your best birthday ever? Why?

  • “I don’t want to be a burden on my son when I die.”

    You could respond: My grandmother said the same thing to my mother. She was never a burden to my mother.

  • “I hope you will remember our talks.”

    You could respond: How would you like me to remember you?

All of these attempts to connect with a patient can pay off in huge personal and professional rewards. “My big thing when elderly patients are in the hospital,” says Dr. Green, “is really paying attention to some of the nonmedical things and using [them] as an opportunity to explore [their personal and home issues] or provide them with the help they need to be able to stay in their homes. It’s huge to be able to send someone home if you can.”—AS

A Matter of Loss

By the time a person is old (over 70) or old-old (over 85) their losses may have manifested in many areas: They’ve lost:

  • Parents;
  • Other relatives—perhaps including children;
  • Friends;
  • Places of residence (both homes and the familiarity of cities or towns);
  • Possessions;
  • Other relationships (sometimes other healthcare providers);
  • Careers;
  • Consultative authority (“ours is not a culture that values the wisdom of our elders,” writes Solie);
  • Identity;
  • Financial independence;
  • Habits and pleasures;
  • Physical space (the room at their son or daughter’s or in assisted living or the nursing home can’t compare to the homes, gardens, and expanses of view they may have had as younger people), and, of course; and
  • Physical and mental capacities.

Sometimes the losses elders sustain occur in rapid-fire sequence, with little or no recovery time in between.1,6

It is no wonder that older adults, in one way or another, exhibit what we consider resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing, overly familiar, or mechanized manner.

“Many patients are resistant to having people come into their homes and help them, and at the same time they are resistant to going to a skilled nursing care facility,” says Dr. Green, “and it has to do with their [feelings of the] loss of independence and control over their lives.”

“It’s very easy if you’re in medicine to normalize your context of the hospital,” says Solie. “In other words, the hospital seems familiar to you and you’re very comfortable moving around there, and mainly because you’re in control. You’re the doctor … and you move in the hospital in order to make things happen and you never feel all that threatened. But when you bring an older person who already has a heightened sensitivity toward losing control into the hospital—this complex, technological world of medicine—and they have the cumulative disadvantage of being sick,” says Solie, “it’s really important to remember that there will probably be no other state that they’ll be in, except maybe nursing home care, where they will feel so out of control.”

A good first step in communicating with older patients is to quickly develop a rapport with them and show them you recognize what they’re up against.7 “They really want to know whether or not I get it,” says Solie.

The way you communicate that you get it, he says, is fairly straightforward: When I’m first interacting with the patient, I say, “if you are like my [other] elderly patients … I’m sure you’re feeling a lot of anxiety over [not having much] control and, first of all, I want to assure you that I’m going to make sure you understand the choices and help you make all the decisions. And … I’m definitely going to … put everything in a language that you understand. But if I’m not successful, I’m going to employ someone from your family. We’re going to work together. Even though you’re hospitalized and even though you’re fighting this illness (or whatever the condition might be), you still [have] the right to make choices, and my goal is to partner with you. My expertise is medicine, but you have an expertise in your life.”

In other words, you are signaling that you recognize that control is the issue. Acknowledge the loss, ask about the value of the event or decision to the patient, ask what you can do to help them deal with their feelings or make up their minds. It also allows you to remind an older patient’s children that control is a big and normal concern for their mother or father.

Many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … it can be helpful for the hospitalist to take time and explore those issues [of loss and legacy].

—Eva Chittenden, MD

Hospitalists at a Different Time and Place

The elderly desperately need people who can serve them as natural healers, who are not constantly in a hurry, and who care what they are thinking and feeling. How can hospitalists relate to those who are in the midst of life review and who are hanging on to an escaping control? How can they serve their patients in a way that meets all needs?

Fighting—with denial or ignorance—the resistance that patients might put up will more than likely provoke them. A fight for control can undermine and sabotage the best intentions of the provider and the greatest wishes for the patient to experience comfort or regain health and well-being. Rather than justifying wresting control from elderly patients because it’s for their own good, advises Solie, what we must do instead is to “step back, hand them the control baton, and allow them to run with it.”1

A person’s admission to the hospital “might be such a huge crisis for them, whereas for us it’s our routine work,” says Dr. Chittenden, who practices as a hospitalist and also works on her institution’s inpatient palliative care service. “And many people who are hospitalists—who are even in their late 20s, 30s, 40s—have been totally healthy their whole life, so it is hard to relate to what it’s like to be older and to be losing function, losing friends who are also dying, losing their house … . I think that it can be very helpful for the hospitalist to take a little more time and explore some of those issues [of loss and legacy]. I try to meet the person where they’re at and try to understand what their goals, needs, ... and fears are [as well as] their functional status.”

Allowing older patients to engage with you about their lives and their pasts is a privilege for any healthcare provider. Engaging with them in a way that will help facilitate their loosening the reins on control may expedite and allow greater quality into their healthcare. It may provide an opening whereby you can order that home-health visit with less struggle.

How to Address Patients’ Perceptions of Loss of Control

  • Watch your tone.
  • Listen (and wait) for the real message, the values.
  • Acknowledge where they are before encouraging them to move somewhere else in a decision. Use sentences such as “I know it is hard to keep going in the face of all these setbacks.” Or “I know you’re dealing with a lot of loss with this new set of news and what’s been going on with you over the past year. How can I help you regain a sense of balance?”
  • Remember that the first “no” may be a warm-up answer.
  • Keep in mind that a change in direction may reveal something else of significance.
  • Consider that explosive responses signal unresolved control issues.
  • Remain patient while listening to the details.
  • Keep your perspective.

It is no wonder that older adults exhibit what we consider to be resistance to their changing lives. In terms of a hospitalization, this may mean saying “no” to medications, individual providers, tests, surgery, home-health visits, or something as small as being talked to or touched in what they perceive as a disturbing or mechanized manner.

Create Openings

“There are a lot of different ‘on-ramps’ to asking the life-review questions, which are extremely comforting,” says Solie. “For example, you might say, ‘Mary, I notice that you were born in Iowa. You know, my family on my father’s side came from Iowa. Where were you raised?’ And ‘Do you have a big family on your farm, because my aunt had cows.’”

Once you get a response that engages the patient, then you “are in the slipstream. Physicians have such a high experience curve, they see so many patients,” he says. “They don’t have to go very far into their inventory of experiences [to find one] that essentially matches up with that patient.”

Any kind of comment that will key you in to their background experience can help establish some kind of foundation for relationship. Another example: “You know, Mary, I was working with this woman who was about your age and she was raised in the Midwest and was dealing with some of these issues of congestive heart failure, and one of her big concerns was something that I didn’t appreciate until I understood what an impact it was having on her life.”

This kind of communication, says Solie, can help to relieve some of the patient’s control anxieties, “because she feels that if I ‘get it,’ she’s open to what I have to say, such as, ‘The first thing, we have to deal with is there is too much fluid going on in your body and it’s putting a big strain on your heart, so the first couple days all we did for that [other] woman was try to pull some fluid off and keep everything in balance.’”

You’ve communicated that you have a plan, that you can be trusted, and that you will help her to exercise as much control as possible. Creating and accessing those openings is also “the ideal way to weave the family into this whole life-review process, which is where the patient lives, psychologically and emotionally, when outside the hospital environment,” he says. “We become so myopic when we’re caught in the hospital environment that the world becomes a narrow tunnel and we forget the greater matrix outside that we’re all connected to.”

The Boon of Biology

Whereas the physiology and anatomy of humans deteriorate with time, some of the changes in mental processes in old age may actually enhance the ability to reflect and make informed judgments. Solie’s view is that what younger people may view as slow behavior, confusing speech patterns, and physical frailty don’t hinder the tasks that are before the elderly. On the contrary, they assist the fulfillment of their developmental agendas to feel in control when they’re losing control and to let go enough to reveal the legacy that will survive after they go.

Research on the aging brain indicates that changes in brain chemistry facilitate the life-review process.1,6 In general, reflection is the normal mode of existence for elderly adults and their primary focus. Thus, viewing them as diminished because they communicate differently than younger people do is doing them a disservice.

Those slowed mental processes, Dr. Chittenden concurs, “are conducive to reflection. Someone younger will pathologize it. … I agree that we don’t value the slowing down process, but I also think that when this population is in the hospital we are tending to look at loss of functional status or the quick mental traits that we value as opposed to [that which is] adaptive [and] that enables them to look at things differently and reflect.”

The key to connecting the dots of where they are and where they need to be (both medically and psychosocially), as well as how they occur to their providers and their families as opposed to how they occur to themselves, is to listen to and speak with them by making use of what you know about this stage of their life as it affects their communication. You can do this, says Solie, by invoking the “access code,” which is “to clearly understand that at the top of their agenda—no matter what else is happening—is the need for control and the need to develop and go after a legacy, and that means life review. If you know that, you will never lose your reference point with them.”

Communication Habits of the Elderly

Solie identifies some verbal behaviors that are common in older people. In many cases these behaviors may reveal something between the lines.

  1. Lack of urgency. Older people need more time to decide things. Accept that slower pace as normal. Don’t take it personally. Adjust your schedule to allow time to deliver news or ask for choices and then allow time for them to discuss with their families or contemplate on their own; return to them at a later time. Become expert at spontaneous facilitation. Use your access code to get their attention and gain their trust.
  2. Nonlinear conversations. Although older patients may appear to wander off topic, they may do so in the urge to ground themselves in what their priorities are, what their feelings are, what their choices will be. Signal you’re willing to listen and that you’re tuned in to the content, even if you don’t know where it is leading. (Obviously, someone who is demented or delirious presents a different scenario altogether, and depression is common and frequently overlooked.) Listen for patterns and themes. Nonlinear conversations can lead to spontaneous revelations and great insights for your patients and for yourself and can help patients revisit life dramas that test and clarify values. This, too, is a part of healthcare.
  3. Repetition and attention to details. In situations when dementia is ruled out, a patient’s repetition may indicate a means to emphasize an important point or value. Keep in mind, too, that as we age, we all repeat stories to some degree. Details in stories may be the means by which older adults connect to their pasts and may also serve as clues to what is important to these people. Don’t assume details demand any action on your part. You are only being asked to listen as the older person sorts things out.
  4. Uncoupling. Solie describes uncoupling as any time an older person appears to disconnect from you in the course of a conversation. For a professional, this can feel as if you are dismissed or ignored just when you think you’ve hit the mark with a comment or question. Go back and assess the information you’ve gathered by doing some verification. Rethink the objective: Any action that works against their maintaining control and discovering a legacy will produce uncoupling.

“I try to be aware of when I’m losing people,” says Dr. Chittenden of this phenomenon. “I would say, ‘I seem to be losing you and I’m wondering what you’re thinking right now.’ I would try to find out where they’re at and if it was something I said that didn’t gel with them, didn’t make sense to them, or wasn’t their priority.” This is something, she emphasizes, that a hospitalist needs to watch for with patients of all ages. “Whether you’re older or younger,” she says, the communication can be complicated because “you’re … in the hospital culture and the priorities of doctors are so often different from the priorities of patients.”

Conclusion

Older and especially old-old individuals in some ways live in an era other than the one traversed by the young and middle-aged.6 Their purposes, agendas, and mission are different and the slowing down of their functioning can facilitate their attempts to put their lives into perspective and manage what control they can still exercise or are still allowed. Viewing older patients with the utmost respect and acknowledging the challenges they face at these last phases of their lives can better help you to partner with them and their families in their care. TH

Andrea Sattinger also writes about the importance of apology in this issue.

References

  1. Solie D. How to Say it to Seniors: Closing the Communication Gap with Our Elders. New York: Prentice Hall Press; 2004.
  2. Chochinov HM, Cann BJ. Interventions to enhance the spiritual aspects of dying. J Palliat Med. 2005;8:Suppl 1:S103-115.
  3. Dennis KE. Patients' control and the information imperative: clarification and confirmation. Nurs Res. 1990;39(3):162-166.
  4. Kiesler DJ, Auerbach SM. Integrating measurement of control and affiliation in studies of physician-patient interaction: the interpersonal circumplex. Soc Sci Med. 2003;57(9):1707-1722.
  5. Breemhaar B, Visser AP, Kleijnen JG. Perceptions and behaviour among elderly hospital patients: description and explanation of age differences in satisfaction, knowledge, emotions and behaviour. Soc Sci Med. 1990;31(12):1377-1385.
  6. Pipher M. Another Country: Navigating the Emotional Terrain of Our Elders. New York: Riverhead Books; 1999.
  7. Barnett PB. Rapport and the hospitalist. Am J Med. 2001;111:31S-35S.

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