As seniors become caregivers to seniors, can doctors lighten their load?
Many caregivers struggle with their own ageing issues. Conversations that lead to more meaningful care can ease their burden.
Tan Kok Yang
A man who looked like he was in his early 60s pushed his mother into my surgical clinic. The mother, who was in her 80s, was frail and her hair was not combed properly. What struck me was that the son looked as tired as the mother. There was a certain anxiety that surrounded this man, and it was evident to me that he was sincere in searching for answers.
Madam M had been referred to my surgical clinic for chronic constipation and consideration for endoscopy. Even without looking at the clinical notes, I could anticipate that she would have multiple documented medical problems and that she would not be a stranger to the hospital systems.
Such a scene is familiar to me. I have an interest in optimising surgery that ensures meaningful outcomes for the elderly and I have run a surgical clinic catering mainly to the oldest patients since 2010. For more than a decade, I would see patients older than 75 years of age referred to a general surgical clinic for gastrointestinal and abdominal complaints. Over the years, I have come to appreciate how difficult it is for caregivers to bring their elderly parents to the clinic, and yet most were very genuinely seeking advice or solutions for symptoms that they perceived robbed the well-being of their loved ones.
It is well known that Singapore boasts one of the highest life expectancies in the world and by 2030, one in four citizens will be aged 65 or above. The effect of such a shift is a significant rise in the number of sick and disabled in the population. It is estimated that each individual will have up to a decade of illness and disability.
There is also another, related knock-on effect. As the number of very elderly patients, who will require prolonged care, continues to rise, we are seeing that their caregivers are also getting on in years. Old people are caring for those even older than them.
The burden on these ageing caregivers is heavy. I think doctors must play a role in lightening this load by facilitating good conversations and goal-setting that ultimately rationalises the care of patients and targets outcomes that are more meaningful, not only for the patients, but also for the caregivers.
Struggling, greying caregivers
An elderly woman, very dear to my heart, was an 80-year-old Chinese opera singer on whom I performed major surgery for cancer back in 2007. We visited her at her home years down the track and were proud of our achievements. Her cancer, though in the later stages, did not recur, despite being treated with surgery alone. She went on to live well for a good eight years after the surgery.
I recently saw her at the age of 96. She had outlived her own daughter, she was in a wheelchair and she could no longer recognise people well, including the granddaughter who had been taking care of her all these years. At our last meeting, I talked to the granddaughter and we reminisced about the years that had passed. There was a tired look on the granddaughter’s face. The granddaughter, like me, had grown in age. On that occasion, I spent more time showing concern to the granddaughter than the patient, because that was the clinical need that I perceived.
The burdens of caregiving must be on many people’s minds, which is why the recent hit movie How To Make Millions Before Grandma Dies has struck a chord with many in South-east Asia. But as these caregivers get older caring for their super-aged loved ones, they themselves are facing significant challenges.
In 2022, Yishun Health conducted a Population Health Survey of residents in the north of Singapore in collaboration with partners. One of the significant findings was the toll that the ageing population had on the caregivers of the elderly.
In that study, which involved a total of 2,499 residents, it was found that 6.9 per cent of the residents were providing regular care or assistance to a friend or family member who had a health problem, long-term illness or disability. The mean age of the caregivers was 47.9 years and 61.2 per cent were female. Of the caregivers, 40.6 per cent had at least one chronic medical condition, 34.8 per cent experienced distress, anger or depression with respect to caregiving and 9.1 per cent felt that they needed help.
The caregivers were also getting older and they themselves had challenges that go beyond that of caring. Often, these challenges go unrecognised and unsupported. As the population gets older, there will be a financial strain on the healthcare system to manage these elderly and sick patients. However, the costs go beyond just financial. There are also significant costs in terms of time and emotional and psychological pressures.
In my Geriatric Surgery Clinic, about three in 10 patients referred for a symptom do not have clinical pathologies that need investigations and treatments. Many of these elderly patients have already been thoroughly investigated. In these three of 10, the patients or caregivers are searching for something that medical repair cannot readily provide: relief.
Sometimes, it is the sense of isolation or the despair of ageing in the patient; other times, it is the caregiver who is tired and confused by the complaints of the loved one they care for, or the advice of numerous healthcare professionals that they have seen. Many express guilt at not being able to provide a solution to their elderly loved one who seems to be suffering from so many different symptoms. Some caregivers have told me that they themselves are suffering from illness and psychological stress.
Don’t pile on the investigations
Coming back to Madam M, she had attended the emergency department several times in the last year and, over the next six months, she had more than 10 appointments for various specialists and investigations ordered by the specialists. She had four upcoming CT scan appointments ordered by various specialists, some from another hospital. The son who brought her to the clinic was the main caregiver and had been taking her to her multiple appointments.
I took time to look at all her medical conditions and helped the son and patient make sense of the appointments and whether they were necessary. I called up the radiologist and arranged for the various CT scans to be combined into one appointment and reduced her clinic consult sessions by more than 70 per cent. It took me a good 45 minutes to do so and I remember the son was very apologetic as he knew that other patients were being held up because of this, but I explained to him that this was essential for his and his mother’s well-being.
Both mother and son were very grateful after the consultation. Some weeks later, the same patient returned to the emergency department for yet another complaint and was offered another scan. But this time round, the son decided to specifically come to seek me and I reassured him that his mother need not go for the new scan.
There was another woman who was in her 60s whom I had been seeing for troublesome haemorrhoids that needed surgery. She was absolutely devoted to the care of her older brother with special needs. Every decision that she made with regard to her own well-being was related to the care of her brother.
I walked a journey of over a few years with her, from rationalising her investigations to finally finding an opportune time window for her haemorrhoid operation. She wanted to be discharged as soon as possible, and not once did she complain of pain after surgery for she had a job to do, such was her devotion. She had to juggle her priorities between taking care of a loved one and taking care of herself. There are many such stories.
From 2017 to 2022, the average age of patients at Khoo Teck Puat Hospital increased by 3.5 years. The needs of the patients are becoming more complex, with multiple medical, psychological and social issues. There is also data that shows that these patients are undergoing more investigations and interventions. Often these are driven by protocol-based medical care and guidelines that are becoming more and more specific and complicated. Many of the investigations and interventions are also performed on persons that are approaching the end of their lives.
We must have more conversations about “appropriate care” and also discuss the financial costs of inappropriate medical care. And, beyond financial costs, let us also be aware that every medical recommendation and decision also imposes a significant hidden cost on the caregivers. It places more of a burden on them at a time when they are getting older and facing their own health challenges as well.
In the movie How To Make Millions Before Grandma Dies, the characters were told that continuing cancer treatment was futile and they went on to find peace and acceptance. For Grandma, it was her show of unconditional love for her children even when they disappointed her. For the grandson, it was the realisation of how precious and meaningful the time they spent together was.
There are lessons to be drawn. Healthcare workers should become more aware that their patients are linked to other persons who care for them and shoulder the burden of medical decisions. Meanwhile, even as they care for others, it is not wrong for caregivers to seek meaningful conversations about their own well-being.
It is time for healthcare workers and caregivers alike to take a critical step back to have more conversations. In many cases, there are really no solutions and what is required is just compassion and understanding and words of encouragement. In these cases, the solution is not medical repair, but, rather, the identification of goals that are truly meaningful, not only to the patient but also to the family.
I suspect that in many situations, the Chinese wisdom of 无为而无不为 (achieve everything by doing nothing) letting nature take its course may well be a viable strategy. Such wisdom can only come through deeper conversations, mutual respect and a heart to understand more. The time must come that conversations and awareness of the relationality between healthcare workers, patients and their caregivers centre the way we provide and receive care.
- The writer is deputy chairman, medical board, and senior consultant surgeon at Khoo Teck Puat Hospital. He is also president of the Geriatric Surgery Society of Singapore.
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