End of Life: Advance Directive

 

End of the Appalachian Mountains. Tannehill Ironworks Historical State Park, Alabama. November 2020. Credit: Mzuriana.

I pondered about this post's category. Should I prefix it death or should I use end of life? 

Perhaps it should be: End of the Fourth Age. 

Or just The End. Or Almost the End. 

Wait. In keeping with this blog's subtitle, A Travel Journal From the Land of Age: 

• End of the Road
• Winding Down
• Going Home
• Travel's End
• Last Stop

Bringing mine up to date

I completed my first advance directive more than 15 years ago, when I was still married and a different state was my legal residence. My husband was my primary health care agent, and my adult daughter, Kit, the backup. 

Very recently, I drew up a new advance directive, which:

1. Declared my daughter as my primary health care agent; and
2. Used a template from the state of my current legal residence.  

My local library provides free notary services, and I availed myself of that useful benefit. 

Where is it? 

• I mailed my daughter a print copy of the new advance directive. 
• I uploaded a scanned copy onto a cloud account that I share with my daughter.
• The original is in a plastic sleeve on my refrigerator, along with the contact information for my daughter and my primary healthcare provider. 

Resource

CaringInfo.org shares good, basic information about advance directives in plain language:

1. What is an advance directive? 
2. Download and complete your state's advance directive template
3. Creating your advance directive
4. Storing and retrieving your advance directive
5. About digital and video advance directives
6. POLSTS (Physician Orders for Life Sustaining Treatment)
7. Power of attorney
8. Choosing a healthcare agent

Rearview sunset on I-10 in Texas. September 2017. Credit: Mzuriana.

Vanity of Age: My Eyes Are Naked

 

Eyes of Duran. New Mexico. July 2017. Credit: Mzuriana. 

I've never been one to wear a lot of make-up, but once I became a woman of a certain age, I religiously applied lipstick and an eyeliner pencil. And more recently, mascara. Every day. 

But now I've been diagnosed with blepharitis (and dry eye). 

So, I've been going out and about with naked eyes. 

I don't like this one bit. 

Lack of eye definition makes me look faded. Looking faded is looking older, more tired, more washed out, less alert, less crisp.  

Part of the issue, I'm coming to realize, is the thinning of my eyelash forest. 

Have I lost eyelashes? If yes, is it due to a non-reversible aging process? Or is it a function of previously undiagnosed blepharitis? Or a COVID consequence? If either of the latter two, will the lashes grow back at some point? 

In the meantime, I'm on the search for some work-arounds. 

Vanity of Age: "You Look Like ...."

Person A (of any age) says to Older Person, excitedly: "Do you know who you look like?" 

Older Person pauses. A moment passes. An inner girding of one's loins occurs.

Older Person asks, in a neutral tone: "Who"? 

Person A: "Jodie Foster!"

Older Person thinks to self: 

Well, I know it's not Jodie Foster in Taxi Driver, obviously. Nor is it Jodie Foster in The Accused. Obviously. Nor Silence of the Lambs. Obviously. 

Bottom line, Dear Self: 

Is it Jodie Foster of today, ready for the red carpet? 

Jodie Foster still for Golden Globes site. 

Or is it Jodie Foster of today, in Hotel Artemis?

Jodie Foster in Hotel Artemis. Found: Bouquets & Brickbats 

Interestingly, in this hypothetical example, Older Person's own hypothetical mother (a More Older Person, may she rest in peace) may or may not have said several years ago: "You look like Jodie Foster." 

Which one????

When Can I Stop Having to Learn New Shit?

 

Brains. Toronto, Ontario, Canada. June 2016. Credit: Mzuriana.

When can I stop having to learn new shit? 

I distinctly remember thinking this thought. It was 2016, and I was in the midst of climbing an irritatingly steep and long learning curve on some new app or program that I needed to master so I could get something I wanted. (Here is the difference between an app and a program.)

I felt very resentful. 

Eventually, I moved past that petulance. I accepted that:

1. If I desired a big and rich life, 
2. I had to keep learning new shit.

To be clear: I'm not talking about learning new shit about history, geology, literature, music, dance, culture, human and civil rights, current affairs and trends, etc. I have no issues with any of this, and in fact, it is critical to my growth as a human to seek new knowledge about our world, in addition to new and diverse perspectives on such. 

No, I'm pretty much talking about new tech as it pertains to devices, processes, user interfaces (UIs), rules and policies, forms management, security/privacy management, fintech, etc. 

To learn new tech, it's not uncommon to have to unlearn stuff. And the older one is, the more stuff one must unlearn. Of course, this process can be uncomfortable. 

The necessity of paradigm shifts

1.      My first smartphone

I bought my first smart phone (an android) in 2013 or so. 

Until then, I had done just fine with my fliptop dumbphone (which is now back in fashion) because I had my laptop and internet access at home. Why did I need to be tethered to the internet when I was out and about? But eventually, I became envious of friends and family who whipped out their smart phones to look something up in the moment - or - most importantly - used their smart phones for driving instructions. 

Mastering my smart phone was a frustrating pain in the ass! Negotiating its bells and whistles seemed so counterintuitive! (It still irks me that I can only go back to a previous page on my phone and not go forward.) At least once I wanted to hurl the phone against a wall. (Emotional maturity does not necessarily come with age.)

Until. 

Until it hit me that I was approaching my android as a phone, expecting it to behave like a phone. But a smart phone is not a phone. It is a very small PC that happens to include a phone app. 

This shift in thinking changed everything for me. Of course it was going to take me time, practice, thoughtful reflection, and problem-solving to gain control over my new device. 

2.      My CPAP machine

I am in the midst of learning the ins and outs of a CPAP machine. 

When I picked it up at the durable medical supply place, the personable technician rolled through the ops quickly, congenially, and capably. She pointed to a stapled collection of papers in the carrying case that she said had step-by-step instructions to support her demonstration. 

As she pushed and turned buttons and the dial, and flipped open latches and closed little hatches, I thought, oh yeah, I've been here before. It seems so easy-peasy now, but because she is not having me actually demonstrate my understanding while I'm there, it's very likely I'm going to forget a lot of what she's saying. ...... But I was silent, thinking of that step-by-step guide I could refer to when I got home. (Spoiler alert: That step-by-step guide pertained to something else, not the machine operation. )

A second reason to have a new user run through the steps herself (to get that memory reinforcement through the physicality of it), while under the technician's eye, is to ascertain the patient understands the instructions AND has the motor dexterity to, for example: push the humidifier drawer latch in, pull the drawer out, flip the water well latch up, remove the well lid, reassemble the water well, and push the drawer back in. 

Physical conditions such as arthritis, tremors, and the lack of finger and hand strength are all potential obstacles to operating the CPAP machine for someone who is older. Furthermore, the machine requires distilled water in the humidifier well - not all older people have the strength and motor control to lift and pour water from a gallon jug, or a large bottle, or a pitcher. 

A third reason to have the patient run through the steps herself is to counterweight the natural anxiety a patient feels during the presentation (and acceptance) of managing a new:

• Device
• Routine to add to one's life, i.e. the cleaning and maintaining the machine
• Way of sleeping

And get this: 

The power button does not turn the machine off. It just starts or stops the airflow. That caused me some consternation. After poring over the user manual, I saw these two items, which are lounging casually within the other collection of text on page 6: 

Text:  Therapy on/off button: Starts and stops the airflow for therapy. 

A note from me: the icon for the "therapy button" is the universal icon for power buttons. 

Text: In a separate section on the same page, there is a note: When positioning the device, make sure that the power cable is accessible because removing power is the only way to turn off the device. 

The most important information in the above text comes at the end of this nonchalant statement. Here is how the sentence should read: 

The only way to turn off the device is to detach the power cable from the machine, so make sure the power cable is accessible. 

Text: But on page 9, #5 in a list of instructions titled Supplying AC Power, it says: 

When turn off the device Press Therapy On/Off Button and the device will stop work. [sic]

(Quality control much?) 

All this bit about the CPAP machine veers off a bit to a rant and also to geragogy, but it comes back to this: Learning how to operate and maintain a CPAP machine is new shit. New shit that I have to learn.

Below is the paradigm shift I needed to soothe my savage breast about this CPAP learning annoyance:  

Remember, MB, you've lost confidence in your usual learning skills because of this, and that is fucking with your head. But also remember that your MO in learning new technology has always been: Steady and studied:   

1. Look at the new app or the new device or the technical glitch
2. Research it
3. Run through a process of trial and error, with the confidence that you can't break it
4. Get it sorted out
5. Done, sometimes needing to retrace your steps if it's complex or you only need the device or the app occasionally, sometimes needing to write down the steps to remind you

Sometimes that self-teaching process was fast; sometimes it was slow. Sometimes I had to step away from the problem and then come back to it after minutes, hours, or even the next day to reboot my brain. 

The process (and the confidence that I couldn't "break" the device) was what set me apart from friends who - no less intelligent or educated than I - panicked at new technology. They either Pushed All the Buttons in a frenzy, creating all sorts of mayhem (but not breakage) or they threw their hands up in frozen alarm position, and called me or any nearby 12 year-old to fix it.  

Remembering this calmed me. I just had to go through the same steady steps that have served me well in the past when dealing with technical stuff. And I needed to grant myself the grace that the anxiety I feel about getting the CPAP operation right is a normal response. 

Moral of this story: I'm going to have to keep learning shit. 

Friends: A Diversity of Age

Fish for dinner. Batumi, Caucasus Georgia. April 2012. Credit: Mzuriana. 

 

The value of having younger friends

When friend Cam was in her early 50s (and I was in my 40s), Cam's grandmother was still alive and independent in her 90s. 

Cam told me two things about her grandmother that have stuck with me. 

Cam's grandmother:

• Walked a mile a day; and
• Developed friendships with people younger than she.

Being in her 90s, Cam's grandmother had, of course, lost many of her contemporary friends and family members. But because she had been intentional in growing friendships with people from younger generations, Cam's grandmother maintained a thriving social network. 

Who do I define as younger? 

At least 10 years younger. 

A decision to find them

I've met folks who prefer that things such as this roll out "organically." To let things happen "naturally." They disfavor goal-driven and action-based intentionality in one's life experiences. 

That's not me. 

If I want diversity of age in my friendships, I can't leave the finding of them to chance. I've got to know what I'm looking for, where I'm likely to find them, put myself in those locations, and make overtures to youngers who interest me. 

Statistically, I know I've got to reach out to 10, 20, maybe 50 candidates in order to find one where there is a mutual affinity. The age differential makes it all the more difficult. 

The difficulty due to the age differential is not because there is a dearth of youngers who interest me. No, it is the opposite. It is because, culturally, the older I become, the less I am of interest to youngers as a group.  

Finding them

For a variety of reasons, I have lagged behind in my goal to seek, select, seed, and sustain friendships with youngers. COVID is only the most recent challenge to my goal. 

I'm chuckling to myself as I write this because I'm remembering a friend who sought a man for a long-term relationship. After some scattershot dating experiences, she created a spreadsheet that included a list of her wants, must-haves, and must-not-haves. For each man she dated, she evaluated him on the spreadsheet. On one hand, this is amusing, and for those of us who prefer an organic approach, it may seem too clinical. On the other hand, it helped my friend stay focused on what she wanted from a life mate and from a relationship. ... And, indeed, she found her mate. 

A former colleague used a fish pond as an analogy for her friend-finding activities. She threw out a line with bait. If a fish bit, she reeled it in. Sometimes the fish was a keeper. Sometimes not. The point was: She fished, regularly. 

Fish mosaic. Batumi, Caucasus Georgia. April 2012. Credit: Mzuriana. 

Language in the Land of Age: Geragogy

 

Library al fresco. Portal, Arizona. March 2013. Credit: Mzuriana.

Definitions

Geragogy: 

"... is a theory which argues that older adults are sufficiently different that they warrant a separate educational theory. The term eldergogy has also been used. ... Source: Wikipedia

Critical geragogy: 

"Geragogy is the method and practice of educating older adults. Historically, the principles of geragogy did not discriminate between educational programs that patronized versus programs that empowered older adults. In the former model, educators control the learning environment and old adult learners take a passive position.  ....in the framework of critical geragogy, ... the older adult learner is in control of their learning and their unique learning needs are recognized and met. In practice, critical geragogy requires older adults to evaluate their experiences with education and advocate for changes that would better fit their needs." [Emphasis added.] Source: Critical Geragogy in Long-Term Care Settings

Contrast geragogy with: 

• Pedagogy, which is, of course, our catch-all term for the method and practice of teaching, although the prefix "ped" refers to children. 
• Androgogy, a term new to me, which refers to adult education. 

Geragogy programs or movements

1.       U3A aka University of the Third Age [specific to the UK]: 

"... [is] a UK-wide movement of locally-run interest groups that provide a wide range of opportunities to come together to learn for fun. Members explore new ideas, skills and activities together. .... membership ... is open to everyone who’s no longer in full-time work." 

Note: "No longer in ... work" seems to be a contrivance to describe those who are retired or being of retirement age, as clearly the "third age" refers to folks who are older. Maybe there's a legal reason for the program to be coy about the target age of its members. To me, it sounds similar to being "no longer in harness," as one might refer to draft horses. 

Per Wikipedia, on the University of the Third Age [general]:

There is no universally accepted model for the U3A. Its original conception in France as an extramural university activity was significantly modified in the United Kingdom where it was recognized that most people of retirement age have something to contribute and the emphasis has been on sharing, without formal educational links.

Many English-speaking countries have followed this geragogic model, whereas continental European countries have mostly followed the French model. For historical reasons, lifelong learning institute is the term used in the United States for organizations that are similar to U3A groups.

2.       Osher Lifelong Learning Institute (OLLI)

OLLI seems in alignment with the French model of U3A. I took courses via the OLLI program at the University of Texas-El Paso (UTEP) on: 

• Civil Rights history
• Mexican history
• Spanish
• Geology of El Paso

All of the 125 OLLI programs in the US are affiliated with universities. The OLLI courses are separate from the regular classes at the affiliated universities. 

3.       Special access to regular classes at a school of higher learning

Every state has at least one college or university that offers older people access to its regular courses at low- or no cost. A list is here. 

4.      Road Scholar (fka Elderhostel)

For those with the financial means, Road Scholar:

".... combine travel and education to provide experiential learning opportunities featuring an extraordinary range of topics, formats and locations, in every state in the U.S., 150 countries and aboard ships on rivers and oceans worldwide." 

5.      More programs here

Examples of cringe-worthy, patronizing geragogy

1.       Papa Pal's guidance on How to Teach Technology to Seniors

Considering that the big bucket called seniors generally begins at 65 ... let's remember that these doddering oldsters invented the internet, shall we? We've been using digital technology in the workplace for decades now. Sheesh. 

The intro: "You’re never too old to learn something new, even technology. Seniors and technology aren’t as mismatched as you might imagine. Many seniors today learn how to use technology seamlessly, navigating the internet and connecting on Facebook — and even TikTok — as seamlessly as younger generations."  Even TikTok! Hoo-wee! One of many reasons that youngers have fled Facebook is because there are too many old people using it. 

"Many seniors worry about security and keeping their private information safe when they use the internet. In an AARP study, 85% of adults ages 50 to 64 revealed that they were concerned about their privacy and data protection while on the internet." Well, FFS. Concerns about digital security are age-neutral and entirely appropriate. 

By the way, with the possible exception of two individuals, all of Papa's 15 leaders appear to be under the age of 50. 

To be clear, it's not the subject matter of this article I deplore - there's new technology coming out every day, and it requires a learning curve for everyone - what I object to is the patronizing, infantilizing tone of the authors - and the lack of any pedagogical (or let's say, geragogical) research to support their guidance. 

2. Brookdale's Tech Tips: 10 Tips for Teaching Technology to Seniors is a mixed bag.

Cringe-worthy: "Avoid technical words and use consistent language. Now that words like emoji and selfie have been added to Oxford Dictionary’s lexicon, tech speak is becoming a part of everyday language. ... Many tech-related terms may be unfamiliar to them. ..."  Seriously? Because elders have lost the capacity to learn new vocabulary? 

I guess this might be related to why grown-ass health care providers ask grown-ass elders if they have to "go potty." 

Now this I like: "Seniors are used to being more knowledgeable and competent at most of their endeavors by virtue of the fact that they have more life experience. It may have been years since they were a novice at something .... "   This recognizes that the student is not only an adult, but an adult with considerable knowledge, skills, and abilities. 

Language in the Land of Age: The Third and Fourth Ages

 

Woman, Benson Sculpture Garden. May 2016. Loveland, Colorado. Credit: Mzuriana.

Third Age definition

The Third Age:

• Marks the culmination of an adult's life, 
• Refers to a person who is age 65 or older, and
• Who is vigorous and healthy, with a positive attitude about life

I surely do like the word culmination. It means the highest or climactic point of something, especially as attained after a long time. 

It's different from a peak. 

We've got a culmination of our dreams. A culmination of our life's work. A culmination of knowledge, skills or abilities that we achieve after hard work or dedication or practice. 

A peak is more mathematical - a high point of a mountain, a price point, a level of athleticism. 

A culmination is the fruit of growth. 

Fourth Age definition

The Fourth Age marks the "period of dependency, decrepitude, and death,"        

Oh, my. 

However, some folks use arbitrary numbers to define the Third Age and the Fourth Age: 

• Age 65 to 80 or 85 is the Third Age
• Age 80 or 85 is the Fourth Age

One discussion on definitions comes from  The Fourth Age: A Period of Psychological Mortality? in 2000 by Dr. Jacqui Smith.

I've chunked the excerpted text for faster digestion: 

1.      Proposals to distinguish a Third from a Fourth Age 

in the human life course came to the fore in the 1980s when researchers in the fields of demography, biodemography, gerontology, and sociology recognized that average life expectancy in western societies had increased ....  (e.g., Pifer & Bronte, 1986; 4 Science Special Report, 1996). 

2.      The definition of subgroups of the elderly population 

was one attempt to specify factors linked to the heterogeneity of the older population in terms of social participation, mortality, morbidity, and service needs.

3.      The precise definition of  [Third Age and Fourth Age]  membership, however, is still an open question. 

• Whereas, for example, retirement from productive participation in the workforce is usually regarded as defining the beginning of the Third Age, 
• There is less agreement about the definition of entry to the Fourth Age. .. .

4.      .... The answer ... depends ....  on whether the Fourth Age is defined by:

• The demographic features outlined above, or 
• Biological, functional, or quality of life characteristics. 

5.      According to the latter perspective, the Third Age exemplifies positive characteristics and the Fourth, dysfunction and death. 

6.      Neugarten (1974), for example, described those

• in the Third Age (young old) as retirees from the work force who are in relatively good health and are socially engaged; [and ...]
• the Fourth Age (oldest old) was typified by the onset of all the negative stereotypes of old age.

7.      Similarly, Laslett described the 

• Third Age as an era of personal achievement and fulfillment, and the 
• Fourth Age as an era of final dependence, decrepitude, and death.

I propose a third definition of the Fourth Age

In the gerontological context, the Fourth Age is that time when a body enters its natural shutdown phase. Or perhaps put another way: The life stage when the body begins to wind down as part of the natural course of things. 

Death will always be the outcome, but there is heterogeneity in the winding down. 

The closing down may take a few years; it may be a few months, weeks, or days. The winding down may be visible to both the one shutting down and to others. Or it may be invisible, having begun days, weeks, months earlier, but appearing sudden, as with one of my aunts, who dropped dead one day while on a walk. 

We can enjoy a rich quality of life during the closing down, even if we have become dependent on others for some of our daily needs, or we suffer some cognitive impairment, or we have lost some of our physical mobility, or if we have a condition that we know will take us down. 

Defining the Fourth Age as a natural shutting down phase makes much more sense to me than the alliterative "dependence, decrepitude, and death." It's the difference between describing a storm-crashed, "decrepit" house and a stone structure that is eroding steadily, but which still offers some bit of shelter from the elements to creatures who need it. There is beauty in the latter; not in the former.  

Existential Crisis in the Land of Age

 

Gargoyle study. Tlaxcala, Mexico. February 2009. Credit: Mzuriana. 

I think I'm in the midst of an existential crisis.

For those of us with a "later-life crisis," it's not so different from the clichéd midlife crisis. 

Some definitions

In Coping With a Later-Life Crisis (Johns Hopkins Medicine) it is ... 

a time when adults contemplate their mortality and the waning years they have left to enjoy life

From Coping With an Existential Crisis, Psychology Today: 

Such a struggle usually involves the loss or wavering of meaning and purpose in life. There might also be a sense of personal insignificance or aloneness in the world. 

In Later Life Crisis: Towards a Holistic Model, the authors note the work of Peter Marris, quoting an excerpt from his work, in which he stated that, precedent to a "Third Age" crisis: 

Often, critical experiences cluster together; illness provokes retirement, retirement provokes a move, the move puts family and old friends at a distance, and in the midst of all this someone dear to us dies. But there may be twenty years of life ahead, or more, and if people are to enjoy a meaningful old age, they have to work through these crises. 

For me, the cluster looks like this, going back to 2016:

• Draconian policies at our borders when people fled conditions in Central America
• Election of Trump, and his subsequent regime, which invited our most malevolent selves from out of the shadows
• Police killings of Black Americans
• Deeply traumatic experiences with members of my family of origin
• Life crises in my adult daughter's family
• COVID and all of its direct and indirect effects, not the least of which has been the amputation of social activities that give me joy, such as dancing
• My mother's death
• The alarming new wave of systemic racism and misogyny in the banning of critical race theory, reproductive rights, freedom of speech and action in our sexual/gender identification
• Invasion of Ukraine
• And, not to be left out: the usual suspects that lurk in the Land of Age

Things to do during an existential crisis

Fortunately (uh, I guess), I can draw on my experience of past existential crises. My responses have typically followed this chronology: 

1. Suffer.
2. Wonder what is happening to me, and why.
3. Decide to take action that will stop the suffering.
4. Gather wisdom from both objective (scientific research) and subjective (other folks' personal experiences) sources. 
5. Read books that offer paths out of the dark forest. 
6. Act on what I learn. 

I am following that same process today. 

What do we want people to say about us when we die? 

This question is intrinsic to a Third Age existential crisis. 

Stephen Covey, in his book, Seven Habits of Highly Successful People, proposed that we ask ourselves this question. And then let our answer guide how we lead our lives henceforth. 

I would add a more basic question: Will people say anything about you when you die? 

What do I want my obituary to say? 

I am in the midst of an existential crisis. 

Your story isn't over. Mobile, Alabama. January 2022. Credit: Mzuriana.