Tough choices with aging parents

By David Solie

Making difficult decisions for parents who are losing control is never easy. At some point in the lives of our aging parents, things slip out of control. They begin having minor car accidents, they become depressed after the loss of a spouse, they forget to pay their bills, or have a serious medical setback like a stroke. The changes may be subtle over time or sudden. As much as we want them to remain independent, events take them off course, and tough decisions need to be made about the quality of their lives.

But how do we let them know that the time has come for them to relinquish at least some measure of control? While there are no easy answers, there are ways to improve the chances that our aging parents will eventually participate in and successfully survive these tough choices.

Work with their developmental agenda to ease decision-makingOur aging parents are navigating two powerful currents that influence every aspect of the final phase of their life: the need for control and the need to discover their life's legacy. This is the developmental agenda of the last stage of life. If you step in and try to take away whatever control they have left, you will only make the situation worse.

Two of the strategies described below—reframing and using familiar stories—will help aging parents realize that the unmanageable situation they are now struggling with is in fact undermining their control. The third strategy—supporting them in their life review—will help them to discover their legacy.

Take a gradual approach to reframing conversationsFirst, help parents recast the situation they’re in. Begin this reframing process by clearly acknowledging that control is critical to their well being and you fully support their need to have control. Your goal is to convince them that you understand their situation. You can say things like:

Mom and Dad, I know you both are proud of your independence and have always made your own decisions. I want to do everything possible to support your independence.

Dad, you know what's best for you. My job is to help you figure out your choices and then let you decide what you want to do.

Mom, no one wanted this to happen. But it did. The important thing is to determine how you want to handle it. This isn't something you have to do alone. All of us will help with whatever you choose.

Next, describe the behavior or circumstances that present a "clear and present danger" to their control. Your goal is to signal that you are concerned about a specific area of their life that is threatened by a loss of control:

Dad, mom is forgetting to take her medication and that has caused her diabetes to get out of control. According to the doctor, if she has a stroke or heart attack you both could lose your independence.

While I am glad the fall wasn't more serious, it looks like you are going to need to have surgery on your right hand. For six weeks after surgery you are not going to be able to use your right hand for even the basic things like eating, bathing, and general chores. Given that you live alone and are very protective of your privacy, this is going to challenge your ability to live independently.

I know it started out as fun, a chance to be with your friends and get out the house. But the trips to the local casino have cost you nearly half of your savings. At this rate, you won't have any savings in six months and will have to get by on social security, sending things further out of control.
Finally, explain how making a tough choice is actually a "control preservation strategy" to prevent the above scenarios from happening. Your goal is to signal there's a way to regain control and you are dedicated to helping them accomplish it:

You both have a chance to bring this situation under better control. Let's talk about the three options that will ensure that mom takes her diabetic medication, and you tell me which one sounds the best to you.

Let's talk about some ways that you can stay in your home as you recover from surgery. While you may need to be flexible about your privacy, it can offer you the chance to control where and how you recover from this operation.

The most important thing right now is to determine what you need to do to regain control of the situation. There are some tough choices, but if you allow me to work with you, we can develop a financial plan to preserve your remaining assets and manage your monthly bills.

Use familiar family stories to reinforce reframingSuccessfully reframing tough choices as opportunities to preserve control is only half the battle. Change is daunting at any age, but especially distressing for older adults who are experiencing losses on so many fronts. Even when it is clear that a tough choice is in their best interest, they may feel overwhelmed by what it will take to actually do it. They need realistic encouragement instead of false reassurance that "things will all work out" or that they shouldn’t worry.

But the encouragement needs to come from someone they trust and believe, someone with whom they have an immediate emotional connection. Finding a well-chosen family story, particularly of older adults, perhaps family members, who have faced similar setbacks but persevered and regained a new measure of control in their lives, can provide both comfort and inspiration.

For example, you could say: Do you two remember when Aunt Ethel found out she had heart failure and was told she might have to go into a nursing home? Remember how she was determined to get better and even her doctors could not believe how much improvement she made? She found a way to stay in control of her medical problem and lived in her own home all those years before she passed away. Dad, remember when granddad had hip surgery? Remember how mad he was when a nurse came in to help him? As hard as that was, granddad made a great recovery and said that his nurse "kept him out of the nursing home." I don’t think you know that Linda’s mom had the same gambling problem. She didn’t tell Linda until most of her money was gone. But together they figured out how to save what her mom had left and worked out a way for her mom to socialize that didn’t involve gambling. Linda was just glad she could help while there was still a chance to regain control of the situation for her mom.

By including these suggestions for conversations, I don’t mean to suggest that tough choices can be managed in such a brief exchange. Rather these suggestions lay out a reframing sequence and signaling strategy that is crafted to resonate with the developmental needs of the older adult.
Remembering that other older adults have faced a loss of control, made tough choices, and gone on to a better life is critical to preserving their hope that they can do the same.

Help them with their ongoing life reviewThe second item on aging parents’ agenda is creating a legacy in a world in which time is running short. Our aging parents are trying to sort out the meaning of their lives and how they will be remembered. To do this, they are actively engaged in constant life review, a reconsideration of the most important experiences of their lives. The very process of making tough choices can evoke strong emotions about the last phases of their lives and what it all means. Asking sensitive questions can help them review their lives and see their current choices in the context of all that came before.

You can say, for example:
Aunt Ethel overcame congestive heart failure to live many productive and happy years before she passed away. What is your favorite memory of Ethel? Was she always so sure of herself as I remember her?
Didn't you say that granddad was a ranch hand at one point in his life? Where was that and how did he get that job?
When I was growing up, you said Linda reminded you of your sister Beth. How is Linda like Aunt Beth?

Legacy is all about discovery, and discovery begins with the right questions. Life review questions like these provide an emotional forum to gather important memories from childhood and reconsider what they mean now.
The tough choices our aging parents face at the end of their lives do not get easier. But we can help them both preserve control and to discover their legacy. Protecting and preserving their sense of control reduces their anxiety, while helping them with their life review opens their hearts and ours to what matters the most.

he tough choices remind all of us that there is a large inventory of events in life we do not control. What we can control is how they are framed and communicated, and this gives all of us the best opportunity to capture their meaning and purpose.

David Solie is the medical director for Marsh Private Client Services in Woodland Hills, California. He is the author of How To Say It to Seniors: Closing the Communication Gap with Our Elders, published by Prentice Hall Press. For more than 20 years Solie has created and been the primary instructor for a variety of educational courses for the insurance and financial services industries. He is a graduate of the University of Colorado Medical School and a licensed physicians assistant with an advanced degree in clinical medicine. He can be contacted at dsolie@covad.net.