In the medical field, resilience is a concept often discussed in the context of children and adolescents. There’s a lot discussion around understanding pediatric growth trajectories and assessing their different areas later in life. These domains include cognitive function, academic abilities, and social adaptations.
With a growing interest in geriatrics, I began to wonder what resilience looks like in elderly patients who, unlike children, present their life trajectories to doctors much later. It may be difficult and even uncomfortable to discuss for those who perceive resilience as a long term goal – overcome important obstacles in order to improve over time. Resilience may not seem as relevant for elderly patients who are nearing the end of their life.
How would the resilience of an 85-year-old be different from that of a 7-year-old?
Can an elderly patient with Alzheimer’s disease who no longer have the capacity to give informed consent be resilient?
What about a chronically ill patient on his deathbed?
I first encountered these questions as an undergraduate student at Dartmouth when I joined Recollections, a choir made up of dementia patients, their caregivers, and student volunteers. On Saturday morning, we met at the Howe Library in downtown Hanover. Gathered around coffee and baked goods, we exchanged greetings. We sat in three rows and practiced familiar songs such as You are my sun, Blue skies and New York, New York. Once a song started playing, even patients who once seemed stoic began to mumble the lyrics. At the end of each song, the hall was always filled with laughter, applause and even impromptu dancing.
Next to me were elderly patients with dementia who continually struggled with chronic illnesses. However, they lived and cherished every moment with their loved ones. What bloomed between every line of every song was the courage and strength that stretched beyond the limits imposed by their diagnosis. In those times, I came to understand that resilience in the elderly doesn’t have to be about long-term improvements. On the contrary, resilience can manifest itself in the here in the form of joy and a sense of connection. Having power over fleeting moments like these, no matter how small, can be important enough to maintain meaning and purpose in the lives of patients and their loved ones.
After I returned to Dartmouth for medical school, I continued to serve the elderly as a volunteer for the Dartmouth Centers for Health and Aging. I have worked with nursing home residents with dementia and helped them complete the Physician Order for Life Sustaining Treatment (POLST). First published in 2019, the POLST form is a standardized medical prescription designed to honor the wishes of chronically ill patients for the rest of their lives. Compared to Advance directives, POLST includes more specific orders for end-of-life care. Since the patients in the nursing home no longer had the capacity to make medical decisions, we called their designated family members to get the patients’ wishes and put them in writing.
I remember a conversation with a patient’s sister in April. After exchanging introductions, I started the conversation by saying, âTell me about your brother. Across the phone, she started talking to me eagerly about her calm personality, her past career as an engineer, her love of fishing, and the annual baking around Christmas. Although its gradual deterioration brought significant limitations to their life and family dynamics, they still found ways to share moments around meals, daily walks around the retirement home, and occasional field trips to the nursing home. downtown. All I had in front of me was the patient’s name, but I could imagine his love life through his sister’s tender voice.
When I presented the POLST form and explained its role as a surrogate decision maker, I encountered a few seconds of silence. Then the patient’s sister began to share her doubts about not knowing exactly what to do for her brother. She also expressed guilt for potentially choosing comfort over aggressive measures that could indicate she was “giving up” on him. After acknowledging his concerns, I said:
âImagine your brother in his prime, standing at the foot of his own bed, watching himself sleep in the nursing home. Imagine he knew what we know about his condition. What would he tell us to do?
This âFoot of the Bedâ scenario, taught during the training of volunteers, aims to help families put themselves in the patient’s shoes. Instead of agonizing over what they or they should do for their loved one, families are encouraged to think about what the patient would have decided for themselves. This change of perspective forms the fundamental core of surrogate decision-making.
âMy brother never liked hospitals. I know he would like to die comfortablyâ¦ âshe declared. Over the next hour, we were able to decide on comfort measures which included orders to do not resuscitate (DNR), no intravenous fluids or feeding tubes, and only palliative antibiotics. Towards the end of the conversation, the patient’s sister expressed a sense of relief that she had had the conversation.
Through my work with the Dartmouth Centers for Health and Aging, I have further refined my evolving understanding of resilience in seniors and their families. The days and hours immediately preceding a death are undoubtedly some of the most frightening. Yet these were families putting their emotions aside and making difficult decisions in accordance with the values ââof each patient. By proactively addressing his physical, emotional and spiritual needs during the dying process, they transformed the last moment of vulnerability into one of resilience. To be a part of this conversation and to help patients maintain their agency until the end of life was truly a lesson in humility and inspiration.
As future health care providers, we are taught to cure illnesses and extend life as much as possible. However, my work with seniors over the years has taught me how important it is to take a break and ask, âWhat matters to you? For some patients, their goal is to live as long as possible using the most advanced procedures, even if it means going to the hospital frequently. There are others who prefer to manage their condition at the retirement home as long as they can enjoy their favorite meal and take daily walks with their spouse. There are also those whose priorities are to maintain comfort and dignity on their deathbed surrounded by loved ones at home. These are surely all equally powerful and beautiful stories of resilience.