Man Oh Stan
Those of you who know me well probably know that I'm not the most directly assertive person in the world. I don't really go for "mano a mano" tests of dominance or wills or whatever. Philosophically, I think that the techniques of winning through domination, manipulation, and lying are fundamental problems in the world. Twisting the truth causes other folks to make errors in their actions, since they're working on false data. This leaves a trail of problems behind. Likewise, domination by force or intimidation warps relationships in very bad ways. Obviously, there are times when these actions are necessary (like war, working with the insane, etc) but they show up way more than they should in our 'normal' society. But I digress. So anyway, I don't like getting into head-to-head confrontation. Well, I had the first of what I suspect may be a string of such confrontations with Doni's dad the day before yesterday, regarding his Diabetes medication. Here's an excerpt from the note I sent to Donita's siblings (primarily directed to her family-practice-doctor husband David) yesterday:
====email excerpt====
Background first: Stan had not been doing his diabetes tests for a long time until around the beginning of March, when he and Doni went to the VA geriatric clinic. At that time, the geriatric doctor told Doni to be in charge of tests and logs. During the first week or two, there was a lot of confusion about following the glucose test process, and I went through the process with him several times (spending about an hour with him each time over a period of a week or so). One day, having done the test several times in a row with readings in the 300s, he came over and said he thought something was wrong, so I spent a couple of hours running through the meter calibration process with him. At that time, he also had trouble with the lancet device that the VA had given him (I think it's a Monoject; he was used to an AccuChek). Anyway, there was confusion.
Knowing that Stan has been misplacing things on pretty much a daily basis, Donita and I thought it was best to give Stan the immediate test supplies, ie, one can of test strips, a few weeks' supply of lancets, etc., but keep the rest of the testing supplies in reserve so as to minimize confusion. While he can, though, we are letting him do his own testing and logging, as David, Doni and I discussed on your previous visit.
Donita and Stan arrived home yesterday fine after a overall-good trip to Texas. While there, he resisted taking his meds (both Molly and Doni tried to get him to take them; "later", he'd say. When they later went to the farm for a few days, he left his meds at Joe and Molly's. He was "on vacation"). Despite an overall good trip, Donita had some difficulty with Stan (at one point she had to stop him from physically intimidating her), and told me that she didn't want to see him "for a week" when she got home.
A few hours after he got home, Stan came over and asked me for more Diabetes test strips and lancets. My memory isn't perfect, but in essence the conversation went as follows: I got out the bag of supplies, and pulled out what he needed. He asked me what was in the bag, so I pulled it all out and showed him (lancets, one more pack of test strips, a calibration kit, and some extra caps for the lancet device; we had gone over this before). He said he needed more lancets, so I gave him half of what was left (about 25 lancets). Stan then asked me to give all of the supplies to him so that he could take it home. I told him that I was uncomfortable doing that, because... and he interrupted me and told me that it was "foolish" to keep it all over here; what if he needs something and we're not home? I continued, I didn't want to do that in order to keep confusion to a minimum... and he said he doesn't know why, but he's been feeling fine for quite some time, and won't mix things up, he always keeps the code cartridge (it goes in the meter and calibrates for a particular pack of strips) with the right pack of strips. We went around several times on this, and it became a test of wills (something I really don't like at all, and which has never happened with me and Stan before). He told me something like "what if I just take all of that home right now?" (I don't recall exactly what he said, maybe "give them to me right now", but my impression was that he was willing to have his way regardless of me) and I said that he should consider whether he wants us to continue helping him with his health. He then changed the subject: "What's in this box" "Those are the test strips." He again asked me to give him the supplies, repeating that it was foolish not to. I told him that "what I began to say to you before is that, although you're feeling good now, and my impression is that you're doing well, I know that you have been confused about these things, and when your mental capacity is diminished, I'm not sure that you're aware of it being diminished." He continued to insist. He said again that he "will not mix things up", and I said that while he has done that in the past, I promise I would not, and he said "I _know_ that you won't" but still insisted. Not wanting to tell him to ask Donita (because I would normally defer to her authority in these matters, but she really didn't want to see him right then), I suggested that if he called David, and if David then told me to give everything to him, that I would. He said something like "fine, then I'll call David", and I said that that would probably be best. I went on to suggest that it's time for him to order more test supplies, and when they come, bring them to me, and I'd give him what I have (to keep stock rotation current). That way, he'd have two sets of strips and lancets, and I'd have a set in case he ran entirely out, or if somehow the strips and coders were confused. I led him outside, and he seemed OK with it and went home.
So you may get a call from Stan about this.
This morning, Stan called me asking where the supplies are that he was to take home last night. I searched where he had been, and didn't find any at our house. I went over to his house, and after a while he found them under a piece of paper in the bathroom. He seemed less "together" today, and looked quite tired. (This happened after his last Texas trip too; it invigorated him, and then he got worse the day after he came home.) Since he skipped his meds and vitamins for most of a week, perhaps that and the stress of travel had caught up with him. Since he skipped his current Alzheimer's med, which carries the warning that you might experience "very severe vomiting" if you cut it off, he may be feeling that too. Doni and I suggested that he start over, ramping up that med dosage (as previously instructed) today.
While reviewing Stan's supplies this morning, I compared his glucometer code with the can that he had been using, and discovered that the code cartridge was from the _last_ can of strips, so his last month's readings have been inaccurate. I disposed of his old code cartridge, installed the new one, and gave him only the strips for that code. The month before (when he was getting very high readings) was also inaccurate, because he had been using (without my knowledge) an expired set of strips. He should only have materials that are current and matching as of now. This morning's fasting test (his first correct fasting reading in a while) was 144, where it had been (erroneously) in the 180s.
I don't normally engage in tests of will, and I felt like a bureaucrat trying to enforce someone else's policy; a novel experience for me. Donita had also described Stan excessively and childishly asserting himself while in Texas. Since Stan asserted that he is fine and would not confuse things, and then lost everything by this morning, I'm pretty sure he saw the irony of the situation. If he tries to assert control about this again, I will attempt to remind him of this incident (which I realize he may not recall). But my overall intentions are to maximize simplicity, minimize confusion (and related distress) and keep the relationship good (ie, not objectify Stan). It's interesting how Stan's well-intentioned acts of volition (trying to 'fix things") can really mess things up; the less he tries to correct things, the better and easier things will go for him and caregivers; it's a matter of balance for all of us.
====end of email excerpt====
Stan really doesn't want his kids "talking about him behind his back" and seems to really fear losing respect, yet he doesn't see that that is inevitable. I think the best way to be would probably be to release the tight control that he wants to maintain, realize that he's fortunate that his kids are sane and loving, and allow them to help him without fighting back. After our confrontation, I'm told he called Donita's brother Drew and argued with him about medications, the family "conspiracy" to control him, and his kids talking about him behind his back. I know that this is hard for Drew, who, like Stan's other kids, have long-developed issues in their relationship with their father. Drew's wife told us that he apologized to Drew the next night; I imagine that his assertion that he wouldn't get confused followed directly by losing the stuff he was demanding from me may have given him pause.
I really don't want to become an insensitive bureaucratic type, but for the first time in my life, I realize through direct experience how the "Nurse Ratchet" personality and behavior develops. You have to somehow accomplish your goals efficiently (without hurting yourself), and sometimes policies just aren't negotiable. That's the nature of control, and control is clearly a necessary part of the caregiver role. sigh... I'm really more the hermit type. Shit like this shakes me up for days. The hell of it is that even though I know what I'd like to reach an understanding with Stan about, I also realize that even if I _did_ actually make him realize that his behavior is driving the behavior of those around him, and the time is rapidly coming (actually it has arrived) where he will necessarily be releasing control of some aspects of his life... even if he saw that and agreed, it would soon be forgotten. With "that dreaded disease" (his term), truly every day is a new day.
For what it's worth, I said this to Doni a while ago, and she says it's made some significant differences in folks she said it to: With Stan, I find that it's best to be in a constant state of forgiveness.
But enough about that....
====email excerpt====
Background first: Stan had not been doing his diabetes tests for a long time until around the beginning of March, when he and Doni went to the VA geriatric clinic. At that time, the geriatric doctor told Doni to be in charge of tests and logs. During the first week or two, there was a lot of confusion about following the glucose test process, and I went through the process with him several times (spending about an hour with him each time over a period of a week or so). One day, having done the test several times in a row with readings in the 300s, he came over and said he thought something was wrong, so I spent a couple of hours running through the meter calibration process with him. At that time, he also had trouble with the lancet device that the VA had given him (I think it's a Monoject; he was used to an AccuChek). Anyway, there was confusion.
Knowing that Stan has been misplacing things on pretty much a daily basis, Donita and I thought it was best to give Stan the immediate test supplies, ie, one can of test strips, a few weeks' supply of lancets, etc., but keep the rest of the testing supplies in reserve so as to minimize confusion. While he can, though, we are letting him do his own testing and logging, as David, Doni and I discussed on your previous visit.
Donita and Stan arrived home yesterday fine after a overall-good trip to Texas. While there, he resisted taking his meds (both Molly and Doni tried to get him to take them; "later", he'd say. When they later went to the farm for a few days, he left his meds at Joe and Molly's. He was "on vacation"). Despite an overall good trip, Donita had some difficulty with Stan (at one point she had to stop him from physically intimidating her), and told me that she didn't want to see him "for a week" when she got home.
A few hours after he got home, Stan came over and asked me for more Diabetes test strips and lancets. My memory isn't perfect, but in essence the conversation went as follows: I got out the bag of supplies, and pulled out what he needed. He asked me what was in the bag, so I pulled it all out and showed him (lancets, one more pack of test strips, a calibration kit, and some extra caps for the lancet device; we had gone over this before). He said he needed more lancets, so I gave him half of what was left (about 25 lancets). Stan then asked me to give all of the supplies to him so that he could take it home. I told him that I was uncomfortable doing that, because... and he interrupted me and told me that it was "foolish" to keep it all over here; what if he needs something and we're not home? I continued, I didn't want to do that in order to keep confusion to a minimum... and he said he doesn't know why, but he's been feeling fine for quite some time, and won't mix things up, he always keeps the code cartridge (it goes in the meter and calibrates for a particular pack of strips) with the right pack of strips. We went around several times on this, and it became a test of wills (something I really don't like at all, and which has never happened with me and Stan before). He told me something like "what if I just take all of that home right now?" (I don't recall exactly what he said, maybe "give them to me right now", but my impression was that he was willing to have his way regardless of me) and I said that he should consider whether he wants us to continue helping him with his health. He then changed the subject: "What's in this box" "Those are the test strips." He again asked me to give him the supplies, repeating that it was foolish not to. I told him that "what I began to say to you before is that, although you're feeling good now, and my impression is that you're doing well, I know that you have been confused about these things, and when your mental capacity is diminished, I'm not sure that you're aware of it being diminished." He continued to insist. He said again that he "will not mix things up", and I said that while he has done that in the past, I promise I would not, and he said "I _know_ that you won't" but still insisted. Not wanting to tell him to ask Donita (because I would normally defer to her authority in these matters, but she really didn't want to see him right then), I suggested that if he called David, and if David then told me to give everything to him, that I would. He said something like "fine, then I'll call David", and I said that that would probably be best. I went on to suggest that it's time for him to order more test supplies, and when they come, bring them to me, and I'd give him what I have (to keep stock rotation current). That way, he'd have two sets of strips and lancets, and I'd have a set in case he ran entirely out, or if somehow the strips and coders were confused. I led him outside, and he seemed OK with it and went home.
So you may get a call from Stan about this.
This morning, Stan called me asking where the supplies are that he was to take home last night. I searched where he had been, and didn't find any at our house. I went over to his house, and after a while he found them under a piece of paper in the bathroom. He seemed less "together" today, and looked quite tired. (This happened after his last Texas trip too; it invigorated him, and then he got worse the day after he came home.) Since he skipped his meds and vitamins for most of a week, perhaps that and the stress of travel had caught up with him. Since he skipped his current Alzheimer's med, which carries the warning that you might experience "very severe vomiting" if you cut it off, he may be feeling that too. Doni and I suggested that he start over, ramping up that med dosage (as previously instructed) today.
While reviewing Stan's supplies this morning, I compared his glucometer code with the can that he had been using, and discovered that the code cartridge was from the _last_ can of strips, so his last month's readings have been inaccurate. I disposed of his old code cartridge, installed the new one, and gave him only the strips for that code. The month before (when he was getting very high readings) was also inaccurate, because he had been using (without my knowledge) an expired set of strips. He should only have materials that are current and matching as of now. This morning's fasting test (his first correct fasting reading in a while) was 144, where it had been (erroneously) in the 180s.
I don't normally engage in tests of will, and I felt like a bureaucrat trying to enforce someone else's policy; a novel experience for me. Donita had also described Stan excessively and childishly asserting himself while in Texas. Since Stan asserted that he is fine and would not confuse things, and then lost everything by this morning, I'm pretty sure he saw the irony of the situation. If he tries to assert control about this again, I will attempt to remind him of this incident (which I realize he may not recall). But my overall intentions are to maximize simplicity, minimize confusion (and related distress) and keep the relationship good (ie, not objectify Stan). It's interesting how Stan's well-intentioned acts of volition (trying to 'fix things") can really mess things up; the less he tries to correct things, the better and easier things will go for him and caregivers; it's a matter of balance for all of us.
====end of email excerpt====
Stan really doesn't want his kids "talking about him behind his back" and seems to really fear losing respect, yet he doesn't see that that is inevitable. I think the best way to be would probably be to release the tight control that he wants to maintain, realize that he's fortunate that his kids are sane and loving, and allow them to help him without fighting back. After our confrontation, I'm told he called Donita's brother Drew and argued with him about medications, the family "conspiracy" to control him, and his kids talking about him behind his back. I know that this is hard for Drew, who, like Stan's other kids, have long-developed issues in their relationship with their father. Drew's wife told us that he apologized to Drew the next night; I imagine that his assertion that he wouldn't get confused followed directly by losing the stuff he was demanding from me may have given him pause.
I really don't want to become an insensitive bureaucratic type, but for the first time in my life, I realize through direct experience how the "Nurse Ratchet" personality and behavior develops. You have to somehow accomplish your goals efficiently (without hurting yourself), and sometimes policies just aren't negotiable. That's the nature of control, and control is clearly a necessary part of the caregiver role. sigh... I'm really more the hermit type. Shit like this shakes me up for days. The hell of it is that even though I know what I'd like to reach an understanding with Stan about, I also realize that even if I _did_ actually make him realize that his behavior is driving the behavior of those around him, and the time is rapidly coming (actually it has arrived) where he will necessarily be releasing control of some aspects of his life... even if he saw that and agreed, it would soon be forgotten. With "that dreaded disease" (his term), truly every day is a new day.
For what it's worth, I said this to Doni a while ago, and she says it's made some significant differences in folks she said it to: With Stan, I find that it's best to be in a constant state of forgiveness.
But enough about that....
posted by Jim at 7:34 AM
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