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Caregiver Decision Fatigue

Caring for aging parents brings with it a new kind of exhaustion called decision fatigue. While its cause has a number of contributing factors, two in particular stand out as primary sources:

• Sustained engagement with dilemmas
• Decision volatility in family systems

Although demanding and stressful, the problems of aging can be contained or eliminated. Lost prescriptions can be refilled. Unsafe staircases can be modified. Transportation for an unscheduled medical testing can be arranged. Solving problems means eliminating uncertainty and most caregivers are well versed in how to do this.

In sharp contrast, the dilemmas of aging defy containment or elimination. They demand sustained engagements with uncertainty, a challenge most caregivers are ill equipped to handle. Consider the following example:

An 84-year-old woman is scheduled to seen by her doctor at her family’s request over her unwillingness to use a walker. She has an unsteady gait, a history of falls and significant bone loss. She lives alone with the assistance of home care services. Her family has tried a number of approaches to get her to use the walker, but she has rejected all of them because she feels it makes her look old and frail.

This situation typifies the nature of the dilemmas, which present as:

• Complex and messy
• Threatening
• Unsolvable
• No-win options
• Decisions must be made

As the family of the 84-year-old woman scrambles to head off a disastrous fall, their challenge goes beyond engaging a dilemma. They must also address how decisions regarding the walker will play out in the family system.

By definition, families are complex systems whose behavior impacts the receptivity and response to intra-family decisions. These behaviors include:

Non-linear reactions—Seemingly minor decisions can carry major consequences. The decision to have the family’s matriarch see the doctor was made by her two daughters without consulting their brother. The daughters were certain their brother would agree with their plan. He and his wife didn’t, and it provoked a heated argument between the sibling’s families about who has the authority to make these kinds of decisions as well as who has the authority to override their mother’s wishes.

Resistance to dictates—Solutions in family systems cannot be dictated. Rather, they must emerge through an idiosyncratic consensus ritual. The flair up over the doctor’s appointment is emblematic of how seemingly benign dictates can rain havoc in the system.

Structural instability—Even the most promising solutions fall apart without warning. Collective consensus in family systems is fragile with emotional crosscurrents and unsettled agendas poised to collapse even the most adventitious decisions. Push back from family members about the lack of communication and consensus regarding the need for the doctor’s appointment resulted in bitter recriminations and the appointment’s cancelation.

Given the stress and complexity of dilemma management within family systems, what are some strategies caregivers can adopt to reduce decision fatigue?

Reorient the big picture—Caring for aging parents involves sustained engagement with uncertainty on an unstable playing field. The rules and expectations of stable, problem dominated environments do not apply. This means success needs to be redefined to allow for messy outcomes and wobbly consensus.

More dancing, less wrestling—The metaphor for engaging dilemmas in family systems is dancing instead of wrestling. Attempts to impose solutions or outthink the structure are doomed and only accelerate and intensify decision fatigue. Honoring the nature of dilemmas by acknowledging that imperfect choices have to be made reduces the endless recrimination over outcomes that are beyond anyone’s control. Honoring the nature of family systems by acknowledging that all caregiving decisions are vulnerable to emotional crosscurrents reduces exhaustive attempts to craft perfect and lasting consensus.
`
Shrinking the horizon—In the non-linear world of dilemmas and family systems, recalibrating the horizon can reset expectations that may have become distorted and emotionally punitive. The reality is that caring for aging parents occurs one day at a time. Recasting the horizon to a daily dance based on “doing the best I can do with what I’ve got” honors our best intentions while restoring a sane estimation of our capacity and limits.

Reorient self-care—Sustained engagement with dilemmas in family systems is not possible without a recovery ritual. Without one, caregiver morbidity and mortality rapidly and tragically declines. While recovery rituals vary in style and content, they all share a common theme. Rest, nurturing relationships, and enjoyable activities. The noble call to do the right thing for aging parents should always include the preservation of the physical health and sanity of the caregiver.

Partner Up—Sustained engagement with dilemmas in family systems is always better with the non-judgmental support of those who have walked the same path. Caring for aging parents is a long game full of dark vignettes, dramatic reversals and thankless service. It is not designed for solo heroics or the faint of heart. Partnering up one on one or in a small group setting is a personal breakthrough for both caregivers and aging parents.

Why Would An Aging Parent Say That?

A reoccurring theme in caregiver support groups is disparaging and derogatory comments made by aging parents to their adult children who are struggling to do the right thing. Voicing anger and bitterness about how their life has turned out, these personal attacks deeply wound the very person who is struggling to protect and care for them. “Why would they say that?” these caregivers ask over and over again. Indeed, why would they?

While each situation is unique, most of these painful scenarios share a common back-story of failed expectations from the aging parent’s perspective. As such, they are tales of people and events that are clearly responsible for their current misery. These stories always blame “others” and are never the responsibility of the aging parent. Sadly, the brunt of the retribution for this poor outcome falls on the caregiver who winds up the loser in a zero sum game.

Ironically, the aging parent’s perspective is only part of the game’s deception. Caregivers caught up in this toxic dance usually harbor their own set of expectations that perpetuate the dysfunctional engagement. Out of loyalty, duty and love, they truly believe that it is within their power, on some level, to find a way to make an aging parent happy. The stories of their quest to find the elusive answer are filled with false starts, extraordinary sacrifice and painful rejections. But in the end, nothing works because there never was an answer.

Most adult children caught up in this don’t want to believe the game is rigged. Instead, they want to be a change agent whose heroic efforts save the day. Unfortunately, none of us possess the ability to change anyone, least of all our parents. While we have deep empathy for their sad circumstances and would go to great lengths to reduce their suffering, their punitive expectations are never ours to repair.

This disturbing insight is difficult to accept. It rejects the myth that adult children have unique powers for changing who their aging parents have become. In this regard, it declares that the game is set in stone. What isn’t set in stone is how adult children choose to respond to it.

Faced with this realization, caregivers have the option, however difficult, of revising their expectations about what is possible. The work is no longer about finding the non-existent secret to their aging parent’s happiness combined with the mythical approval for a job well done. It is a more healthy set of marching orders that continues to honor the commitment to provide compassionate care but is based on more realistic and self-protective goals.

This proves to be a monumental revision in the parent-child relationship that is easier said than done. Their life-long emotional advantage of parents over their children asserts itself with surprising force at any attempt to alter the game. This usually presents as dramatic outbursts, high-powered manipulations, and an escalation of derogatory comments. Dogged persistence and resilience are required to withstand this predictable and unpleasant pushback. Even then, it’s always a messy and unsatisfying process.

But armed with new expectations, the shame of never finding the impossible slowly begins to recede. While the bitter comments still hurt, little by little they begin to ring false and are seen for what they are, desperate attempts by an aging parent to shift the responsibility for his or her role in their situation. While the game continues, the choice to reject its premise and declare a different interpretation and response has altered its impact, a shift in the balance of power that comes none too soon for caregivers.

Aging Parents: Problems versus Dilemmas

Although demanding and stressful, the problems of aging can be contained or eliminated. Lost prescriptions can be refilled. Unsafe staircases can be modified. Transportation for an unscheduled medical testing can be arranged. Solving problems for aging parents means eliminating uncertainty and most caregivers are well versed in how to do this.

In sharp contrast, the dilemmas of aging defy containment or elimination. They demand sustained engagements with uncertainty, a challenge most caregivers are ill equipped to handle. Consider the following example:

An 84-year-old woman is scheduled to seen by her doctor at her family’s request over her unwillingness to use a walker. She has an unsteady gait, a history of falls and significant bone loss. She lives alone with the assistance of home care services. Her family has tried a number of approaches to get her to use the walker, but she has rejected all of them because she feels it makes her look old and frail.

This situation typifies the nature of the dilemmas, which present as:

• Complex and messy
• Threatening
• Unsolvable
• No-win options
• Decisions must be made

Given the stress and complexity of dilemma management within family systems, what are some strategies caregivers can adopt to successfully navigate them? Here are some suggestions:

Reorient the big picture—Caring for aging parents involves sustained engagement with uncertainty on an unstable playing field. The rules and expectations of stable, problem dominated environments do not apply. This means success needs to be redefined to allow for messy outcomes and wobbly consensus.

More dancing, less wrestling—The metaphor for engaging dilemmas in family systems is dancing instead of wrestling. Attempts to impose solutions or outthink the structure are doomed and only accelerate and intensify decision fatigue. Honoring the nature of dilemmas by acknowledging that imperfect choices have to be made reduces the endless recrimination over outcomes that are beyond anyone’s control. Honoring the nature of family systems by acknowledging that all caregiving decisions are vulnerable to emotional crosscurrents reduces exhaustive attempts to craft perfect and lasting consensus.
`
Shrinking the horizon—In the non-linear world of dilemmas and family systems, recalibrating the horizon can reset expectations that may have become distorted and emotionally punitive. The reality is that caring for aging parents occurs one day at a time. Recasting the horizon to a daily dance based on “doing the best I can do with what I’ve got” honors our best intentions while restoring a sane estimation of our capacity and limits.

Reorient self-care—Sustained engagement with dilemmas in family systems is not possible without a recovery ritual. Without one, caregiver morbidity and mortality rapidly and tragically declines. While recovery rituals vary in style and content, they all share a common theme. Rest, nurturing relationships, and enjoyable activities. The noble call to do the right thing for aging parents should always include the preservation of the physical health and sanity of the caregiver.

Partner Up—Sustained engagement with dilemmas in family systems is always better with the non-judgmental support of those who have walked the same path. Caring for aging parents is a long game full of dark vignettes, dramatic reversals and thankless service. It is not designed for solo heroics or the faint of heart. Partnering up one on one or in a small group setting is a personal breakthrough for both caregivers and aging parents.