At 90, Millie appeared to be complacent with age and content having others tell her what to do. Every morning Millie experienced transient vertigo while getting out of bed. She happened to tell her visiting nurse about it and she detected an irregularity in Millie’s heart rate and elevated blood pressure. She recommended Millie go to the emergency department.

Millie’s daughter-in-law, Jen, was contacted because her son was out of town. Jen was well-aware of Millie’s history of hypertension and atrial fibrillation. The emergency physician examined Millie and determined that the vertigo occurred when she sat up along the left side of the stretcher (the same side she normally got out of bed). There was no evidence of a stroke and vital signs were essentially “normal.”
The physician made light of the situation by pointing out that Millie needed more exercise and suggested she enlist in boot camp. Her debilitated state and deliberate moments were not conducive to living independently. Millie also had mild cognitive impairment which was destroying her confidence and ability to age well. She was setting herself up for failure. By virtually saying, “C’mon now,” the physician compared Millie to an athlete making a big mistake.

Millie had exceeded life expectancy, but was it dumb luck or strategic? At what point did Millie think she was too old? Aging tends to creep up on most people and doesn’t occur at one specific birthday. If age has its privilege, can it also be strategic? Like Millie, most people resign to the “come what may” approach. Millie may not care what happens to her at this point, but Jen and her husband do and they’re caught in the conundrum of being damned if they do and damned if they don’t care.

The resolution to this no-win situation is to begin advance care planning with strategic aging in mind. Aging is defined as having a chronic illness with physical limitations or mental impairments.

There are three goals tor strategic aging:

1) Prioritize Quality of Life
What matters most to Americans is freedom. “Give me liberty or give me death” are the immortal words of Patrick Henry that have inspired generations to prefer freedom as a way of life. Your state of independence (physical, financial and competency) determines your quality of life.
Strategies that support quality of life:

• Well-being (belief in your spirit nature) instills confidence in making personal choices
• The goal of accentuating the positive allows for leaving well enough alone
• A strong-willed support system combats the high-strung medical system
• The practice of self-determination (saying “yes or no”) keeps you in control
• Being willing, able and ready to overcome fear allows you to achieve goals
At first glance, Millie was well-kempt and appeared to have good quality of life. Yet she was barely getting by on her own without significant help. Millie would not likely admit this, and others are often kind to not point it out. Millie did not think anything was wrong with her when she arrived at the emergency department, but she did not have the wherewithal to go against the nurse’s recommendation. Lacking self-confidence, resources or purpose does not support quality of life.

Manage Chronic Illness
“At least I have my health” does not apply to people aging with chronic illness. Chronic illness means you’ll never ever get better and this will likely be the cause of death. Like fate, you rarely have control over a fatal medical diagnosis, but you can manage the disease. As often stated, “It’s not what happens to you, it’s how you respond that matters.” Is chronic illness viewed as the worst thing that could have happened or a window of opportunity? Which affords peace of mind?

Strategies to living with chronic illness:
• Admit you have a chronic illness that has no cure
• Believe that a higher power can restore sanity
• Decide to allow the will of God or nature to take its course
• Make a list of do’s and don’ts that lead to serenity
• Reduce stress through participating in recreational activities

Using a spiritual approach like the 12-step program for alcohol dependency creates a different treatment plan for chronic illness. As people become older and sicker, they depend a lot on physicians. Physicians usually practice defensive medicine, ordering more tests and finding more medical conditions to treat. This becomes addictive and is not an effective coping strategy for managing chronic illness. Did Millie truly understand the risk she took in coming to the emergency department and having Pandora’s Box opened?
2) Appreciate Palliative Care
Compassion is shown to the aging by offering them free choice between refusing and accepting medical intervention. Refusing advanced medical care often means the patient will die and is not normally seen as a viable option. Patients with chronic illness often claim, “I can’t live like this anymore.” These patients prefer to remain at home. Palliative care provides these patients peace of mind through effectively managing their symptoms at home. Palliative care is not the end of the road, it’s an integral part of life’s journey.

Strategies to better appreciate palliative care:
• Palliative care stands apart from hospice and “shelters” patients from advanced medical care
• It aligns with compassionate, conservative, person-centered home-based care
• It deploys common sense nursing skills over the medical knowledge of highly-trained specialists
• Instead of practicing defensive medicine, palliative physicians just treat the symptoms
• Palliative care nurses advocate for listening to patients’ goals and values

Strategic aging becomes cyclical and generative. As patients appreciate palliative care, their quality of life improves and they can better manage chronic illness. Many studies have proven that palliative care reduces the “insanity” of frequent emergency department visits and hospital readmission.
With Millie’s no-win situation with aging, Jen was damned if she didn’t do. If Millie was enrolled in a palliative program, Jen would not have been damned. The palliative care nurse would have given Jen permission to pass on taking Millie to the emergency department, offering supportive home services. With both palliative and end-of-life care, there’s little need to involve physicians.
Advance care planning is often discussed in terms of completing an advance directive and assigning a medical power of attorney. Although these forms are useful when patients can no longer speak, it’s more important for them to enact a strategic plan that prioritizes quality of life, manages chronic illness and appreciates palliative care.

Emergency physician, Kevin Haselhorst, MD, an expert on advance care planning, speaks to patients, family members and healthcare providers about advance directives, palliative care and dying with dignity. He’s the author of “Wishes To Die For” and “Is Palliative Care Right for YOU?”
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