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IN PRACTICE

When someone is no longer safe at home

DAN PAGE for The Boston Globe

A moving van pulled up to my house the other day. It contained the last of my mother’s belongings, a few pieces of furniture that neither my brothers nor I nor our children had wanted. It’s been over four years since Mom died and we finally gave up trying to sell the things down in Florida, where they’d been sitting in storage.

Among the items was a china cabinet fashioned from an antique harpsichord. It’s dark and ornate and so it wasn’t surprising that no potential buyer in the tropics pictured it fitting in amid the turquoise and wicker. It doesn’t fit in my house either — literally. I had to put it in my garage, the damn thing is so tall. But Mom loved it. The harpsichord followed her from her newlywed apartment to the house in which she and Dad raised us to their empty nester condo to her retirement place. The ungainly mass of mahogany was, no doubt, one of the reasons Mom found it so hard to leave her home, even long after it made sense to do so, long after she became forgetful and unsteady on her feet.

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As I progress from early middle age to, at the very least, middle middle age, I’m becoming more aware of the ways in which some people prepare to be old. One friend tells me he’ll move to an assisted living facility when he’s 70, whether he needs to or not. Another, a healthy woman in her 50s, built a master bedroom suite on the first floor of her home to accommodate her parents when they visit — and her and her husband, in the future, when they can no longer climb stairs. Yet another plans to relocate from Boston to New York, where his children have settled, to spare them the burden of having to travel hundreds of miles to care for him when he’s elderly.

I admire my friends’ practicality. I know, first hand, how hard it is on adult children of elderly parents who haven’t prepared so meticulously. My brothers and I caught countless last-minute flights to Florida to deal with the medical emergencies that befell Mom so frequently in her last years. In my practice, I’ve urged many older patients to sell their homes, give up their cars, and accept more help when it becomes clear that they are no longer safe, or able to take adequate care of themselves. “Surrender some independence in order to gain a better quality of life,” is my usual pithy line.

And yet, when I imagine giving up my own home, I find it hard to be so unsentimental. How could I abandon the view from my bedroom window of the moon through the white pines? The kitchen table I designed myself, at which my kids did their homework? My peonies? Have I been too casual in advising elderly people to leave home, or even to accept unwanted help at home? For some, loss of independence is a worse fate than falling.

I had reason to consider this recently when a patient of mine, a woman in her 90s who lived alone, began doing poorly. Anne had suffered a lot of loss. She was a widow who had, tragically, survived both of her children. Still, she remained charming, funny, and more interested in others than in herself. Anne was always immaculately groomed and, I imagined, kept an immaculate home. This was confirmed when her former doctor, my retired colleague, paid her a social visit. “You know those homes that are so neat there’s not so much as a stray drop of water in the sink?” he reported. “That’s what hers is like.”

Even when she developed severe chronic back pain, Anne insisted on doing her own housework. Her grandchildren helped with errands and transportation, but Anne made it clear that she wanted no help at home. Her home was hers.

In the last months of her life, Anne started hearing voices. Such hallucinations are not uncommon in older people who have never had any history of mental illness. She became convinced that neighbors were harassing her, and called her grandchildren or even the police to complain about them. She also fell several times, seriously injuring herself on two occasions. After those incidents, Anne accepted a part-time home health aide reluctantly, but continued to do much of her own housework.

One day, Anne came to the emergency room after a fall. She was admitted overnight, found to have no fractures, and she asked to be discharged home. Her grandchildren were alarmed by this prospect and, to be honest, so was I. How could we send Anne home when it was so obvious she was unsafe there? It was only a matter of time before she broke her hip — or worse.

But Anne was competent to make this decision and — as I reminded the family and also myself — we had no right to incarcerate her in the hospital against her will.

The day after Anne went home, she was back in the emergency room, this time with chest pain. Lab tests and EKGs indicated that she was having a heart attack. At 94, it seemed unlikely that Anne would benefit from aggressive interventions, and she did not seem to desire them. She thanked me — after asking how I was doing! — and instructed me to say goodbye to her former doctor for her. Then she turned to her grandchildren and told them she loved them, and not to cry for her. Then, a few hours later, she died peacefully.

I couldn’t help but think that Anne saw her independence slipping away and decided to leave home on her own terms.

Meanwhile, I’ve been wondering if I might have the legs of the harpsichord shortened so it would fit in my living room. But I also wonder whether the presence of that precious object in my home would just make it harder, one day, to leave.

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. Read her blog on Boston
.com/Health. She can be reached at inpracticemd@gmail.com.
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