by Amal Awad
Gerald takes his criticism a step further. He suggests that the lack of personal connection has severed the traditional relationship between pharmacist and local customer. ‘I’ll give you an example. You can probably tell me the name of your hairdresser. You can probably tell me the name of your nail technician if you go and have your nails done. What’s the name of your local pharmacist?’
I have no idea of mine, but, to be fair, my parents know theirs well. They’re on a first-name basis.
Gerald would like to see pharmacists take a more proactive role in identifying changes in their customers, to ask more probing questions. He blames a lack of communication skills. ‘I just remember in pharmacies I’ve owned we would have people dispensing at a great rate of knots, and people sitting in chairs waiting. And I would often spend hours just sitting in those chairs. “What’s going on?” “Who do you follow in the footy?” Having a discussion about something other than the illness that they are convinced is running their lives.’
He likes to see how his patients are tracking; whether family or others are coming to visit them; what they might have had for breakfast. ‘I’ve got a GP friend of mine who greets’ – Gerald shakes my right hand with his right hand, and touches my shoulder with his left hand – ‘He greets you like that, he says “Hello” and he says that from the muscle tone in their shoulder he can tell how physically robust they are.’
The doctor Atul Gawande, author of Being Mortal, regards a geriatrician who checks feet. The feet will tell you everything about this person: how well they’re being taken care of, how clean they are, the health of their body as well. You can tell a lot from a person’s feet.
‘This whole engagement thing could revolutionise pharmacy,’ Gerald says.
‘Do you think pharmacists should be doing more on home visits?’ I ask him.
‘Absolutely, but someone’s got to pay.’
Gerald says that at one time, he would take three people for afternoon tea once a month, through his clinic. ‘I would say first in, best dressed. I don’t care whether you’re a patient or not. If you want to join me for an hour, I’ll give you a cup of tea and a sandwich at a local restaurant … This isn’t a consultation one on one, remember – there are other people there, but you all each have fifteen minutes …”.’
Indeed it wasn’t a clinical intervention – just a chat about their health, and it was offered at no cost to the person participating in it. They could tell Gerald things like, ‘I’ve got blood pressure and it’s badly managed, and I do everything the doctor says and I do everything the pharmacist says and I’m still out of control.’
Gerald would offer his views, including advice to discuss things with their doctor.
‘I’ve had people tell me that the letter I’ve written to their doctor is just torn up. In front of them. And one of those ladies said to me, “I don’t go to that doctor anymore.” Interestingly, what I suggested in the letter was done. But never acknowledged.’
I think a lot about this later. Help – simple in its need, sometimes difficult in its accessibility. And it takes me back to Gawande, talking about feet. Of all things, feet. I think of how diabetics should be extra vigilant. I don’t push Dad on a lot of things, but I book him in with a podiatrist. I don’t ask, I just do it. As luck would have it, she’s a sweet lady – she calls dad ‘sweetheart’, and is always smiling. Dad is comfortable with her. It’s a small thing, but it’s significant.
‘Serious clash’
Medications can certainly be a minefield. Professor Richard Lindley, a devotee of computer-assisted medicine, has a series of medical applications on his phone so a database is but a touch away. He logs into an app. ‘We were last looking up vaginal cream for oestrogen, for atrophic vaginitis, so there you go,’ he says cheerfully. ‘But I’ve got all this full data on my computer.’
We’re at the George Institute, located in one of the several buildings that constitute the Royal Prince Alfred Hospital (RPA), where Professor Lindley is a professorial fellow. He is also professor of geriatric medicine at the University of Sydney, and a clinical geriatrician at Blacktown Hospital, with an office based at Westmead. And somewhere along the way, he found time to pen the book Stroke: The Facts, the contents of which he describes as a ‘sort of stroke for the intelligent layman’.
Professor Lindley continues selling me on the advancements of technology. ‘I’m a great believer for dangerous stuff like medication that if the professor has to look up the side effects or interactions of medications, it’s not embarrassing for the resident to look it up. Because I’d much rather people be safe.’
He leaps up to offer a quick example. ‘We’ve got a drug interaction and I can just …’ he types in the names of two drugs. ‘Old people are often on far too many medications, so … you can see people that are on this drug and they’re not very well.’
If there’s a clash, it comes up red.
This match comes up red on the screen. ‘Serious clash,’ Professor Lindley declares. ‘And you can’t possibly learn all the interactions of every medication because there’d be millions and millions of combinations, but as I’ve just demonstrated in five seconds, I’ve got the answer.’
He looks pleased, understandably chuffed at the swiftness of modern advancements. I think of how many people I’ve met with who have fridges filled with medicine boxes; of all the children of ageing parents who worry about how many medications their parents are on; of the pharmacists who tell me they are but a question away, if only people would ask.
‘Well, you know if you’re on six or more, the chances are you’ve got an adverse drug reaction,’ says Professor Lindley. ‘Statistically.’
‘We don’t see our role as extending life’
‘If you practise Western medicine, unless you’re a paediatrician, everybody’s doing geriatric medicine – they just don’t realise it,’ says Dr Naganathan. ‘They all are. The average age of people in an acute hospital in Sydney is roughly about seventy-eight, seventy-nine. So everyone is doing geriatric medicine.’
A hospital full of old people is a sign your medical system is good.
‘People are living longer, and not many young people are getting infectious diseases. In countries like Australia we have little HIV, TB; we haven’t got malaria.’
As the head of the Concord Clinical School, Dr Naganathan has worked as a consultant geriatrician for seventeen years. He is also an associate professor at the University of Sydney, where he teaches and is involved in research. I’m keen to draw out his perspectives on extending a life when it’s not necessarily a fulfilling one.
We discuss the frequent refrain ‘I don’t want to be a burden to anyone when I lose my independence.’ Unquestionably people are living longer. One of the big questions being asked about ageing is: at what cost? What quality of life follows life-saving procedures? ‘I can speak for geriatricians … we don’t see our role as extending life,’ replies Dr Naganathan. ‘We see our role as trying to help people … meet what they want. What I do know is that until you’re older and potentially frail and have got medical problems, you don’t really know what you’ll think about it. And you may look at yourself when you’re young, and you look and you go, “No way. There’s no way I want to live with that.” And then when you reach that stage, you go, “Actually, you know what? I’ve got a lot to live for.”’
People have a higher threshold than they thought. People also change their minds.
‘I’ve had people who’ve been sick, who when they’re sick will say, “I don’t want to live anymore.” And then they get through it anyway, right? Then you see them three months later in clinic, and they’re enjoying time with their grandchildren. And then you ask them, “Was it worth it?” And they go, “Yes, it was.” But they got through because they got through. We might not have done anything to help them get through, but they got through. We human beings change our minds even on life and death decisions.’
It’s indeed worrying how definitive peopl
e are when idealising their own death, or drinking the miracle-solution-to-stave-off-ageing Kool Aid.
‘What do you do with that when somebody’s convinced of one thing?’ I asked Dr Naganthan. ‘If you have this patient who says, “I’m sick and I don’t want to be here”? And then three weeks later they’re like, “Well, I’m glad I got through.” What role do you play in that?’
‘We play a big role … Not just the doctor, the whole team plays a big role in working out how far you go, what the limits in treatment are.’
He explains the concept of limits of treatments when someone is sick in hospital. ‘There are levels of treatments from … maybe we’ll go from simple to harder, right? Someone comes in with an infection. The simplest levels of treatment are antibiotics and fluids. [What if that person has]end-stage dementia and has, what most people would think, no quality of life. Well, they can’t tell us, so we will ask the family, “If they could talk to me, do you think they would want antibiotics and fluids for their pneumonia or urinary tract infection?” Something that is very simple to treat, right? So we do our best to give people a choice, even if it’s asking their family.’
Dr Naganathan says that not being given a choice on treatments like antibiotics and fluids is an issue. He gives the example of a nursing home patient coming in to hospital with end-stage dementia. With quality of life in mind, the patient’s family is consulted about possible treatment scenarios – and after discussion with the medical team decide that no CPR, ICU, intense treatment or dialysis should be given.
‘Then I might ask, “But did you give them a choice in antibiotics and fluids?” And there’s silence on the other end of the phone. And sometimes if I feel they don’t get it, I go, “Well, if that was you, would you want fluids and antibiotics?” And they go, “No.” And I go, “Yeah, neither would I.”’
It raises an interesting ethical question for doctors about initiating active treatment which they themselves in the same situation would not want. Dr Naganathan says that care must be taken with how the choice is presented to the family.
‘Is there an emotional edge to this, though, for you?’ I ask him.
‘Oh, no. No, no, no. It’s a very simple question. And the way to do this is to say to the family, “Tell me about your father’s quality of life.” And then you’d say, “Now, if your father could speak to me, what do you think he would say about being given fluids and antibiotics to help him pull through this pneumonia?” Take that as an example. And sometimes family will say, “Actually, now that you’ve put it as a question of what my dad would want, I think I know. Usually people ask me what I want, and I want you to give the fluids and antibiotics, but now that you’ve put it from Dad’s perspective …”’
Dr Naganathan offers up a statistic: that in such a situation involving fluids and antibiotics, 50 per cent of families would agree to it; the other half would say no. He hopes that point provides reassurance to the family that whichever choice they make is a ‘perfectly reasonable’ one.
Friday
My father never expresses regret about coming to Australia. He always says, ‘It’s a beautiful country.’ He appreciates its landscapes; he’s travelled far and wide, exploring with my mother. He has built himself into the success he always wanted to be, and he links his achievements to the country he chose as his new home.
It was supposed to be a temporary move.
‘When I told my father I was coming here, he asked where it was. A friend had told him that once I take Australian citizenship, I won’t come back. I was planning to stay five years.’
A year later, the Six-Day War erupted. Dad is no longer a citizen of Palestine. In order to remain one, my parents would have had to return there every year.
Dad remembers his first return to Palestine following his move to Australia. It was 1975. ‘The Israelis were waiting for me.’ He was strip-searched on entry. ‘I asked them: “What did I do?” Their response: “Nothing.”’
‘Did it hurt to have to answer to them?’
‘Yes.’
Checking my father’s ID for ‘security’ reasons, an officer queried him on Arrabeh, his hometown. ‘Where is it?’ the guard asked Dad.
He provided its exact location, short of coordinates.
‘Are you trying to tell me that you came all the way here from Australia to this place?’
Dad’s instant response was an emotional one. Arrabeh was his home. He tells me the soldier, in an unusual move, apologised for offending him. Such interrogations aren’t unusual. As Dad says plainly, ‘We Palestinians have suffered a lot.’
En route to Palestine in 1975, Dad was subjected to similar questioning in Egypt, for three hours.
Dad has always been the helper kind. He quickly made friends in Australia, men like him – Arabs who had left behind families, a homeland, a culture as familiar as their reflection. I piece together a sense of the excitement and confusion of this eruption of new life – uncharted territory, a new language, a fresh way of being.
Dad tells me stories. Of what he did for these friends –helping them with language difficulties; his finding work; getting a driver’s licence; finding a partner. He’s not anchored to the past, he’s able to relive it in bursts, to recapture his youthfulness and ambition, his appetite to help everyone he knows.
That was Dad. In some ways a different person to the breadwinner I grew up with. The same but different. It is an aspect of his character that takes on new meaning when he speaks of my grandfather, a man who didn’t express love easily; fierce, a survivor. Dad was always a dutiful son, always good to my grandparents. His every visit became more than a reunion, it was an offering. My father had left his family to build a life elsewhere, a sacrifice that began when he first moved to Germany. And with every return home, he would invest in his family’s security and comfort, each act of generosity an affirmation of loyalty and love.
3.
A THRONE FOR THE CRONE
People’s stories are lessons in humanity.
Among pagans, there is a tradition called ‘croning’.
‘If we think about our society now, it’s not cool to be old,’ says Stacey Demarco, self-titled ‘modern witch’. ‘Especially women.’
Croning occurs later in a woman’s life, after she has stopped menstruating – in her fifties, sixties, seventies, eighties. ‘I think one of the best cronings I have ever been to was for someone in their nineties, and it was the best. So what happens is, you invite all your friends, and at first it’s only women. So this is all your friends and their kids who are female.’
They decorate what is called ‘a throne for the crone’. In the old days, when throning a crone was tradition, she would be carried in. There are refreshments, and the guests gather around the crone in a semicircle on the floor. ‘She is the wise woman, the archetypal wise woman. How many times do we do that in our society now, when we look at an older woman and go, “I want a bit of that”?’
Stories told are not sentimental reminiscences. They’re brief and designed to impart experience, the primary lessons of this woman’s life. ‘Here’s my wisdom I’m going to pass on to you, right? So, “I learned early that it’s best to do this, and you young ones out there, try to do this.”’
Some of the women present will stand up and share positive memories of the crone. ‘“You have given me this”; “I remember you said this to me and it changed my life.” And to just hear that. To hear, at maybe ninety, that someone’s life has changed because of you – and it might have been simply, “You made me the best biscuits I ever had and I needed that at the time because I was going through this terrible situation and I hated myself.”’
The fun part, Stacey says, is that questions are written down for the crone to pull out of a box. ‘And she answers them like an oracle. One of the questions might be “What’s your advice about men?” Or, “I have a boyfriend who does this, what should I do?” And generally the answers are hysterically funny or just beautiful. There’s laughter, ther
e’s tears. And then everyone is allowed in, so the men in the family. And a few of the key people there talk again about what they’ve learned from this woman.
‘Then comes the feasting. The woman walks a spiral, the labyrinth, but she walks inwards. A maiden would walk a labyrinth out. But the crone is signalling that she is keeping her wise blood within and her wisdom is held tightly. And she’s signalling that it’s time – “I don’t know how much I have left, but I’m giving it back to where it came from.” It’s transformation. And I can tell you every woman who’s been to a croning – a very positive croning – has gone, “I want one of those, I want that for myself.”’
It’s not that common in Australia, but Stacey thinks it’s done in the US. She’d love to see it take hold here. ‘It’s something I’ve got on my big list that I’d like to organise for people, because I think it helps with ageing; it helps with your self-esteem as you age. The women I know who have had a croning, oh my god, they’re on a high.’
It’s a practice at odds with the modern view of ageing – that it’s punishment, or an anomaly; it wasn’t meant to happen. But it’s the natural way of things. Like the change of seasons, and the cycles they represent, our bodies go through these stages, and we seem to grapple with each one.
Nobody wants their body to fall apart, to lose its rhythm, to struggle with the toll of years of life. But, as Stacey suggests, ‘We’ve got to have a pay-off. To me, the pay-off is [that] you’re collecting wisdom, you’re collecting perspective. I’m getting to this age now where I say, oh, I’ve seen that before. Do you know what I mean? I’ve seen people do that before, or, wow, I’ve seen a pattern there. I know how to handle it.
‘So as a pagan woman, looking at cycles, working the cycles intimately, from the lunar cycle to the seasonal cycles … you don’t even have to be spiritual about it. [You can decide], okay, it’s winter, probably smart for me to go a little bit more introverted, for me to do my planning now – I don’t have to be so extroverted. We have biorhythms in our body. We have all kinds of cycles – as women with menstrual cycles, that’s a really easy thing to see.’
