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.”