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Volume 3, Number 1
VIEWPOINTS
Old and Vulnerable: The Struggle for Personal Control
ANNE BROCKENSHIRE, RN, MS
Institutionalization threatens the autonomy and independence of elderly people. In long-term care facilities, patients struggle to maintain personal control over their lives in order to maintain their self-esteem and personhood. Health professionals need to develop care plans which reflect a belief that older people have the right and responsibility to be self--directing.
Chronic illness and perhaps eventual admission to a long-term care facility present a serious threat to fundamental values of independence and personal control. Throughout our lives, we struggle to gain and maintain control of ourselves and our lives.
The concept of personal control is particularly important in the management of chronic illness. Chronic illness can erode self-esteem and the sense of mastery and induce feelings of "oldness." It has been hypothesized that those older people living in homes for the aged who make active attempts to control their environment (and who consequently have greater expectations of personal control) are more self-contented and adjusted to old age (1).
For those who live in long-term care facilities, the issues of autonomy and personal control are intensified. Privacy and freedom of movement are lost in the institutional environment and autonomy is restricted. When older people with multiple chronic illnesses experience this environment, the potential for powerlessness is high.
In one nursing research study, Ryden (2) explored who determines what is done in eight areas of daily activity. The areas included ambulation, dressing, eating, grooming, toiletting, group activities, one-to-one activities and solitary activities. Grooming and eating were seen by most patients as the areas where they had the least personal control.
In long-term care facilities, the patient is expected to become accustomed to group living and learn to get along with a roommate within a short period of time. Caregivers will tolerate rebellion and tantrums or withdrawal just so long before assuming control over the patient. The nature of that control may vary from withholding cigarettes to tranquilizing the patient and applying mechanical restraints. Through deprivation of a whole range of independent actions, the older person is told when to eat, when to wash, when to use the toilet and when to sit, stand or lie down. Quickly, the adult loses touch with what she once was, and what she is now. Finally, she loses control over what matters most - her own body.
Many times, it is our greetings, postures, promises and scoldings - all condescending in nature - that further diminish the older adult. There has been little attention to infantilization of older people - that is, treating them like children for the purpose of controlling behavior. Being scolded or sent to one's room are experiences unacceptable to adults. Sadly, scoldings are probably the most commonly used technique. Patients soon learn new ways of surviving - perhaps by withdrawing.
Everywhere, the "whens, wheres and hows" of life are spelled out so that choice becomes unnecessary. Patients are made fully aware of what changes in their lifestyle are required. Even the building structure serves as a control. Patients do not have the option of bringing a lot of personal mementos into long-term care facilities. The greatest shock of institutionalization is a permanent loss of freedom, privilege and choice. Few avenues for personal control remain.
Some older patients have symbols of personal control that suffice in the absence of real influence. For example, a cane or a purse can convey authority. When caring for vulnerable patients, we need to be alert to their symbols of personal control. These may include money, the presence of family, hoarding of supplies or food, refusal of meals or demanding small or large amounts of attention. We need to respond to the latent message of a need for personal control and work with the older patient to reinstate legitimate control. For example, we might want to establish some choice in the events of the day to compensate for the lack of control over the chronic illness.
Health professionals often have very strong ideas about treatment and hospital routines; sometimes, in our zeal to influence, we overemphasize the "shoulds" and "musts." Even though staff constraints may make it impossible for patients to have a bath whenever they wish, a sense of control may be encouraged by offering limited choice. One could say, for example, "You decide whether you would rather have your bath in the morning or the evening." Ryden's finding, that grooming and eating are areas where the greatest percentage of patients see themselves as having the least control, suggests that these may be important areas to target when planning ways of increasing patients' autonomy and sense of personal control.
I worked in a home for the aged one summer. I remember an 89-year-old woman completing her life's work - a book called "Learning to Remember." The nursing administration designated one of the conference rooms as the woman's office, and a desk, filing cabinet and typewriter were moved in. Elated, I remember her saying to me, "I feel like a whole person now! I have a place where I can spread out and be me!" The conference room was also my "office," but the woman assumed I had been hired as her secretary. On one particularly frustrating morning, when things had not gone well for this woman before coming to the office, she told me with tears in her eyes that she was made to have a bath. She was tired of people telling her what to do and when to do it.
Health professionals need to develop a careful treatment plan for institutionalized elderly people that will enhance their personal resources and maximize the positive outcomes. Caregivers need to consistently communicate a clear belief in the right and responsibility of the older person to be self-directing, and offer choices whenever possible. In this way, we may alter not only the objective extent of personal control by patients, but also the subjective perception of personal control.
Anne Brockenshire, RN, MS
561 Creekview Circle
Pickering, Ontario
L1W 2Z9
REFERENCES
- Reid DW, Haas G, Hawkings D. Locus of desired control and positive self-concept of the elderly. J Gerontol 1977;32:441-50,
- Ryden MB. Morale and perceived control in institutionalized elderly. Nurs Res 1984; 33(May/June) :130-36.
How Osler Came to Japan*
SHIGEAKI HINOHARA, MD
As a physician who deeply respects Dr. William Osler and one who regards him as a spiritual mentor, I was greatly honored when, in 1984, the Board of the American Osler Society made me the first Honorary Member of the Society from the Orient. It is in this connection that I would like to tell the story of how Osler came to Japan.
Tokyo University Medical School, which opened in 1877 with a faculty from Germany, was the first medical school in Japan to teach Western rather than Oriental medicine. Subsequently other medical schools were opened; all were based on German medicine, with the exception of a private institution in Tokyo, Jikeikai Medical School, which taught British medicine. In 1887 Dr. Riichiro Saiki went to the U.S. to attend the University of Pennsylvania School of Medicine as a transfer student. He graduated after 16 months during which he had an opportunity to study under Osler (1). After returning from the U.S., Dr. Saiki became a practitioner in Kyoto, and later established the first school of midwifery in Japan.
In 1909 a Chinese version of Osler's Principles and Practice of Medicine (fifth and sixth edition) was published. It was translated in Japan and printed by the Missionary Printing Co. in Yokohama, but all the books were shipped to China without being brought to the attention of Japanese medical professionals. So it is probable that, before the end of World War II, besides Dr. Saiki, only a few physicians in Japan had had a chance to study clinical medicine from Osler's textbook.
St. Luke's International Hospital in Tokyo was built by Dr. Rudolf Teusler, a medical missionary of the Episcopal Church who came to Japan in 1902 from West Virginia. Dr. Teusler hoped to introduce Japan to the American hospital system and establish a model hospital. Finally, in 1933, after decades of arduous effort, he built a modern 400-bed hospital. Unfortunately he died shortly after its opening.
Now I would like to explain how I came to know about Sir William Osler. I graduated from Kyoto University Medical School in 1937 but throughout my student days and house-staff years I did not have an opportunity to read even a single textbook from the U.S. In those days, it was customary to write even a patient's medical history in German.
Immediately after World War II, during the military occupation, St. Luke's Hospital, where I was working, was turned into an American army hospital. We were asked to discharge all the inpatients within two weeks and to remove our medical records and the books from the medical library. However, being a former staff member of the hospital, I was allowed access to the American army medical library. Since I was left without my inpatients, I spent about a month in this library studying American medicine. During this period, while reading Western textbooks and medical journals, I frequently came across Osler's name.
One day, shortly after the War ended, I was asked to make a home visit to the then Prime Minister of Japan, Kijuro Shidehara. Mr. Shidehara was suffering from pneumonia, but because of the post-war turmoil, no hospital bed was available in Tokyo. Before setting out, I visited the office of the Chief Surgeon of the Occupation Forces (known as MacArthur's Office) to get some penicillin. One of the surgeons offered to drive me in his jeep and to accompany me on the home visit. On the way I told him that I wanted to read some of Osler's writings. This surgeon -Lieutenant-Colonel Robert Brount - reported my request to the Medical Director, and the Director spoke to the Chief of Surgery. Later, the Chief (who many years later I discovered was Dr. Warner Bowers) sent me a copy of Aequanimitas, which he had brought with him from America.
Some time later, while sorting the books that had been removed from the hospital library, I found a copy of the second edition of Osler's textbook, as well as Cushing's The Life of Sir William Osler. These were among the books left by the late Dr. Teusler, the former director of St. Luke's.
Shortly after this I fell ill with tuberculosis and was confined to bed for nearly three months. During this time I read Aequanimitas and the Cushing biography of Osler. Both made a profound impression on me. I was determined that Osler's teachings and the impression he had left on the art and science of American medicine would be widely known among Japanese physicians and students. The first material evidence of this determination appeared in 1948 - a 229-page biography in Japanese, entitled The Life of Dr. Osler: The Pioneer of American Medicine. Because postwar Japan had not yet recovered, paper was in short supply and we could print only 1000 volumes.
In 1951, I travelled across the Pacific to Atlanta, Georgia, to study for one year at Emory University's Department of Medicine, then chaired by Dr. Paul Beeson. This year spent at Grady Memorial Hospital in downtown Atlanta was truly rewarding and influenced me profoundly. There I learned the method of bedside teaching that Osler had first demonstrated at the Johns Hopkins Hospital. I was more determined than ever to introduce this new approach into medical schools and teaching hospitals in Japan. Until then they were based exclusively on German medicine and placed a heavy emphasis on basic sciences. I saw at once that Osler's method had moved the teaching of medicine out of the laboratory and into the patient's room.
In June 1952, on my way back from Emory, I went to Duke University in Durham, North Carolina, to meet one of Osler's pupils, Dr. William Davison. Twenty years later, in 1974, on another visit to the U.S., I visited another Osler pupil, Dr. Emile Halman, at his home in San Francisco.
After my year at Emory, I began to introduce internship and residency training programs into Japanese hospitals, with a hope of upgrading clinical teaching. On many occasions at medical schools and elsewhere, I spoke about Osler's philosophy and teaching methods. However, because Osler was practically unknown to Japanese medical professors and students, only a few showed interest in him. However, in 1968 Dr. Masakatsu Abe, President of Jikeikai Medical School and a good friend of mine, began to present the Osler Medal to young scholars who completed their Ph D work under his guidance.
My history as an Oslerian also includes an extraordinary event: the first hijacking of an airplane in Japan. My ordeal began on the morning of March 31, 1970. Shortly after the plane took off from Tokyo, as it approached Mt. Fuji, nine young men armed with swords announced their intention to force the plane to fly to North Korea. At that instant Osler's great word "aequanimitas" flashed before me and penetrated my heart. Under the spell of his words, I was able to recover my composure. Thereafter, until the end of the four-day ordeal (during which I was confined to the aircraft) I kept myself calm by reading The Brothers Karamazov. I had picked this from among a dozen books the hijackers had brought on board and offered to the hostages to read. An account of this experience has appeared in Texas Report on Biology and Medicine (2) Vol. 20, No. 4, 1971, and in the Davison memorial issue of the American Journal of Diseases of Children (3) Vol. 124, Sept. 1972. In a foreword to another published account of this experience, Dr. Grant Taylor told its readers that I was looking for a Chief of Surgery in the U.S. Army of Occupation who had given a young Japanese physician a copy of Osler's Aequanimitas. As a result, I received letters from several North American Oslerians and was finally able to identify Dr. Warner Bowers, with whom I established a correspondence.
Dr. Bowers, who is the author of Interpersonal Relationships in the Hospital, is now retired and living in Huntington, New York. At a memorable meeting with him at his home, I learned these facts: Lieutenant-Colonel Bowers, who gave me his copy of Aequanimitas about two months after the war had ended, was Chief of Surgery of the American Army Hospital and was the highest-ranking surgical consultant to General MacArthur's Headquarters. Later he became Dean of the New York College graduate school. During the war, he carried a copy of Aequanimitas on board his hospital ship and read it thoroughly during the nights. He landed in Japan six weeks after the war ended and started his service at St. Luke's Hospital. It was this precious volume, which he had carried with him and read even while on wartime service, that he had presented to me. I was deeply moved by this.
Since this god-sent encounter with Osler through Dr. Bowers' kindness, I had been captured by the spirit of Osler. In 1972 I began a serial account of the life of Sir William Osler, a detailed narration, in the Japanese medical journal Medicina. After 10 years and 112 essays, it was completed; I am now preparing it for publication. In 1981, Dr. M. Rabkin, President of Beth Israel Hospital in Boston, introduced me to Dr. I. Beck. With their help I was able to examine original material on Osler at the Countway Library at Harvard University.
Also, I have completed a translation of Aequanimitas into Japanese. For this volume, I selected 15 addresses from Aequanimitas plus three others: two written after the second edition of Aequanimitas was published in 1906 ("Sir Thomas Browne" and "A Way of Life"), and Osler's last address, "Old Humanities and New Sciences," written in 1919, the year of his death. Altogether the book contains 18 addresses with 858 footnotes, along with a brief biography, and my essay on Osler's philosophy and teachings. The book, entitled Heisei no Kokoro, was published in September 1983 and, in six months, sold out its first printing of 5000 copies.
The Life Planning Center is a non-profit voluntary organization in Japan and I am the Chairman of its board. In September 1983, we organized a two-day symposium in Tokyo with the theme of "Art and Science in Medicine and Nursing," to which we invited four experts from Britain, Canada, and the United States. On the closing day, the Japanese Osler Society was inaugurated, with enthusiastic participation by the many in Japan who had developed an interest in Osler and his teachings. The Society's objectives were expressed as follows:
From a wide range of literature written by William Osler (1849-1919) himself as well as from other material on his life and philosophy, we hope to learn Osler's ideals and his scholarly achievements. We will also study the training systems of physicians and other health professionals which he developed, and community health activities which he conducted outside the professional institutions. Through these we hope to deliver, to the health professionals and to the younger generation entering this field, Osler's legacy to medicine - a spirit of humanism and scientific research, We further hope to introduce to all the people of Japan the message of Osler's spirit of humanism which he manifested by his own life.
One of the visitors from Britain, Dr. R. Twycross, delivered his greetings as President of the Oxford Medical Society; on this occasion, he wore the very medal that Sir William Osler himself wore when he served as President of the society in 1890. On the same occasion, Dr. J. McGovern, through the kind offices of Dr. Grant Taylor, displayed a plaster relief of Osler's mask, which he presented to the new society. Now over 200 doctors, nurses, and medical students are listed as members of the Japanese Osler Society.
The spirit of Sir William Osler came to Japan in 1945, the year World War II ended, and remained more or less dormant for some time, but in the past 10 years has won keen interest and enthusiastic support among health professionals.
Osler's thoughts and the value of his bedside teaching have become widely known in Japan. All of us hope that the ties now established between the Oslerians of the United States, Canada, Britain and elsewhere and those here in Japan will be strengthened in the years to come.
Shigeaki Hinohara, MD
The Life Planning Center
Sasakawa Kinen Kaikan
12-12, Mita 3-chome Minato-ku, Tokyo 108, Japan
REFERENCES
- Golden, R. Osler and Oriental Medicine. Princeton: Science Press Assoc., 1982, p. 47.
- Texas Report on Biology and Medicine 1971;20(4).
- Am J of Disease of Children 1972;124.
*This paper was presented at a luncheon meeting of the 1984 Annual Meeting of the American Osler Society, in Philadelphia.
Nursing Homes: Reflections on a Recent Visit
WILLIAM J. MOHAN, PHD
Personal experience often raises moral questions. A recent experience with a close relative in a nursing home raised for me a fundamental issue arising from the struggle between duty and practice. Specifically, the problem is that of completing in practice what in theory one sees as duty. This problem may be intensified when one has the task of teaching medical ethics. From the personal perspective, I offer a set of questions about nursing homes and the care of the elderly but, at the same time, suggest why such questions may not yet have suitable solutions. I close with some recommendations for further progress.
It can be difficult to visit a loved one in a nursing home, especially if you have attempted to care for that loved one at home and failed. I teach moral issues in contemporary health care as a member of the Department of Philosophy at Marywood College, Scranton, Pennsylvania, and recently tried and failed to keep my mother-in-law at home. Part of the difficulty of visiting my wife's mother, Mary H., at her nursing home derives from the conflict between the moral theory upon which my teaching is based and the painful reality of a personal health-care experience.
In other words, one may see the duty that theory requires and yet fail to recognize the pain and difficulty involved in the practical performance of that duty. Accordingly, my recent experience suggests that moral questions about nursing homes will beg for practical solutions unless such questions adequately address the inevitable tensions between theory and practice.
We are always somber after visiting Mary H. She lives in what can be described as one of the better nursing homes in Pennsylvania.
On the whole, the home is clean. The bedrooms are adequate for double occupancy. The administrators and staff seem efficient, if not overwhelmingly dedicated to the care of the elderly. The main activities take place in a good-sized, drably decorated, properly sanitized "recreation room." The television blares constantly while people securely strapped into wheelchairs stare blankly at such programs as "General Hospital."
Our visits are never in any other room but this main "recreation room." We never visit Mary in her bedroom - the only place where we might have some privacy. But why should she invite us into her bedroom? She would never have entertained us in the bedroom of her home on Vista Street, where she lived for over 30 years and raised two daughters and a son. Thus our time is spent in the "recreation room" surrounded by other residents, and we talk, or try to talk, above the occasional shouts and cries, above the rattle of dishes being prepared for supper and above, of course, the blare of the T.V.
On every visit we made to the home, until he died, Mr. S. would join our discussion, invited or not. Often Mary H. would meet his intrusion with defiance but she never sent him away. Most of the time he would listen impassively to our conversation. On occasion he would speak sorrowfully about being old, saying to no one in particular: "Nobody wants you when you get old," or "There is nothing to do but wait." Now and then, he would ask what time it was, each time informing us that his primary activity for the afternoon was waiting for the supper bell, often three or more hours away: "Nothing to look forward to, nothing to do," he would mumble, as tears flowed gently down his cheeks. At these times I would think of theory, and the concepts common to my course on medical ethics, such as competency tests for the elderly, and justifiable and nonjustifiable acts of paternalism, and the autonomous nature of Mr. S., Mary H. and the others in that "recreation room." I was struck by the remoteness of all that theory from this palpable and painful reality.
We never stay more than a few hours, chiefly because Mary H. is uncomfortable when we see her, as she puts it, "in this condition." In theory her discomfort may be understood as due to lack of self-esteem or a sense of dignity (being confined to the nursing home), but her full meaning is beyond the grasp of concepts or theory.
When she had the stroke five years ago at the age of 69 my wife, my children and I agreed that we would do all in our power to keep "Mother" out of any nursing home. Like many who teach medical ethics, on many occasions, I had railed against the loss of self-esteem, the loss of autonomy, and the very challenge to a person's dignity fostered by such places. Our moral duty was to avoid nursing home care, if humanly possible.
True to our words, we took Mary H. into our home, hoping to provide her with as much comfort as possible, as long as she lived. The project was an unmitigated disaster: a complete divorce of theory and practice. I knew my primary duty was to care for Mary H. After all, I am sympathetic to the Kantian moral view. But, I was unable to deal with the circumstances associated with the practical performance of such duty. At times the physical and psychological demands arising from her very dependent condition were intolerable. I was not able, for example, to continually lift her to bring her to the supper table or most sadly, to talk with her as often as I should, though when she spoke it was only briefly. I cringed each time I heard her ring "that damn bell" - the one I gave her. Especially troublesome were the 3:00 a. m. rings to ask what time it was. For nearly six months we tried. But I grew the most weary. I could only marvel at the strength and spirit of co-operation of the others. It soon became obvious that Mary H. needed more care than we could possibly provide.
Other family members conducted the search for a decent nursing home - a subject Mary H. refused to discuss. The nursing home chosen was not close to our home, but it was close to Mary H. 's former residence on Vista Street, and close to her son, two sisters and friends. All said they wanted to visit Mary H. as frequently as possible. Thus, the anticipation of frequent visitors eased somewhat the prospect of institutionalization.
The trip to Mary H. 's new and last home was sad. I drove the 100 miles with my wife huddled in the back seat with her frail mother. We arrived and she settled in. We, were advised to stay only briefly, so as to ease Mary H. 's transition to her new home. We left that day as we have left each time since, with great sadness.
Mary H. has grown accustomed to her lot. Those in the know said she would. Like many such residents she has developed a dependency on the home and a sense of serenity about her plight. She accepts the fact that she will die in this nursing home. Her house and most of her possessions are gone. A partial annihilation of the previous self is a prerequisite of continued existence in the institutionalized setting. She is stripped to a great degree of her decision-making powers. Her new life deprives her of the power of substantive decision-making, of which she is still capable, over even the most simple aspects of her life, such as choosing the furniture for her bedroom, what time she should awake in the morning, what time she should go to bed.
Until Mary H. 's stroke I had never been confronted with a serious practical problem in health care. Yet I had spent many years educating others about the basic moral principles involved in serious health-care issues. Clearly, the principles taught must have practical application - that is, there must be a direct relationship between theory and practice. I had no doubt that there was such a relationship though in my classes I have never sought any specific way to demonstrate it. For the first time I became aware of perplexing problems in the human struggle between duty and practice, between the principle and the consequences that follow from adherence to principle. I understood that theory enabled me to reflect on moral duties in health care, but I had not perceived that theory in some way depends on the practical performance of such duties, each performance with its own set of difficult and painful circumstances.
As a teacher of moral issues in health care, my primary responsibilities are to assist anyone who wishes to learn to be intelligently aware of what is involved in holding a moral point of view: part of this is to make him or her aware of the many difficult problems that attach to "applying a moral point of view." My nursing-home experience vividly contrasted the two responsibilities. I was teaching what is involved in holding a moral point of view in health-care issues to the neglect of the many difficulties of applying that point of view.
Care of an elderly, infirm loved one forced me to think in a new way about my responsibilities in teaching moral issues in health care. For example, along with a discussion of moral theories such as Kantian ethics and utilitarianism, I should pay more attention to such questions as the following: If nursing homes are necessary (and I think they are), why can't they be better places to live, or, as Mary H. says, "better places to await death"? How can we, as families and nursing-home administrators, minimize the losses suffered by the elderly? How can we, as family members, become partners in the care of our institutionalized loved ones?
An answer to that last question depends on the attitude of policymakers to the care of the elderly. Are we, as a society, emerging from a negative embarrassed and fearful attitude toward the aged and aging? I don't think so. I don't think Mary H. thinks so either. If we, as a society, were emerging, then why would we not be making simple changes in our nursing homes? For example, why are most nursing homes still basically operated on a "medical model" and not on a "social model"? Why are the residents of nursing homes not encouraged to make virtually every decision that affects their daily lives and activities, except those requiring medical expertise?
Nursing-home administrators would tell me that my value-oriented questions are pertinent but that practical solutions are difficult. All solutions must take account of practical consequences, because after all, at the heart of the education of public administrators lies the doctrine of pragmatism.
These questions, formulated from the perspective of personal involvement, lead to recommendations for further study, which may lead to improvements in nursing-home care. Three of these recommendations are designed to preserve and foster Mary H.'s greatest possession - her dignity. First, compensate for physical losses. For example, even though Mary H. is in a wheelchair, she should have the opportunity to leave the nursing home, say, for a visit to a restaurant.
Second, nursing-home administrators should assist residents to become more involved in decisions that affect their lives - for example, allow residents to choose the furniture or the color of the paint in their rooms.
Finally, and most important, administrators should form partnerships with families in the care of loved ones. Whatever theory we offer to accomplish such partnerships - and we must continually offer theory to guide our practice - must give rise to practices rooted in a spirit of love, co-operation and sacrifice.
William J. Mohan, PHD
Associate Professor
Marywood College
Scranton, Pennsylvania
USA 18509
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