Richard Smith: Calculating our debt to the old

richard_smith_2014My mother, who has had no short term memory for nine years, has lived in a nursing home for almost three years. I visit her most weeks, but I constantly fret if I should visit her more or less. What, I ask you, reader, is the way to calculate the right amount of time to visit? In most countries the old are increasing and the young decreasing (I’m on the border): most of us will face calculations on how we deal with the old, and many of those calculations will be much more difficult than mine.

If I was living in a low or middle income country my question wouldn’t arise. People from those countries, perhaps Africans or Bangladeshis, would never put their mother into a home. They have great respect for the elderly, and an elderly parent, no matter how infirm, would live with them, probably in an extended family. They see it as a moral failing of our society that we will hand over the care of our parents to others, people who have never known them when young and active.

But I can’t say that I ever contemplated having my mother live with me and my family; nor did my brothers. And (this may be rationalisation) I doubt that my mother would have accepted it. She was conditioned to think that if she couldn’t care for herself then she’d go into a home. I think the same, although I’m keen to avoid going into a home—to the point of killing myself if can muster the courage and equipment and find the right time.

So no calculation was necessary in relation to my mother coming to live with us. It wasn’t a possibility, but for others who might be willing to have their parents live with them it is calculation—and no doubt a difficult one. My calculation—of how often to visit—is much easier, but I still don’t know how to make it.

My mother likes it when I go. Her face lights up when I arrive, usually on a Sunday morning. Her greatest delight in life is to walk, and we walk together through the grounds of what was the Surrey Lunatic Asylum. It’s green and peaceful. We talk constantly, and so long as we stick to the distant past, abstractions, and stories I have to tell, somebody overhearing our conversation might not realise that my mother is demented. She uses complex language and has a sense of humour. After walking for about three quarters of a mile we go for a coffee in the golf club, and today I read to her from my father’s memoirs. Sometimes I show her videos of her great grandson on my iPad. It’s jolly.

After the coffee I walk her back to the home. We sit in the lounge, and after a few minutes I say “I’m just going for a pee.” Then I leave. I hate leaving her with deception and without a kiss, but it is better than her coming with me to the locked door of the home as that upsets her. It always made me think of her leaving me at primary school and me begging her to stay.

I usually am with her once a week for just over an hour. Some weeks I’m away and I miss my visit.
But why once a week for an hour? Why not every day for two hours or three hours? Or why not once a month? How can I calculate the right time?

I have no doubt that she likes me to go, and so that suggests I should go every day. But then again she is not aware of me not going when I don’t go for two weeks, and she forgets that I’ve been there even before I’ve left the building. Perhaps then once a month would be ample.

It’s a duty rather than a pleasure to go, but I quite like it when I’m there. It’s a step away from the turmoil of the real world and relaxing to amble through the grounds of the asylum talking about nothing. I sometimes put to my mother problems I’m trying to solve—including this one of how often I should visit. She always says “You don’t need to come often. You’ve got a busy life.” Her generation is programmed to say that. Although I quite like it when I’m there, I’m always glad to leave—and I never leave without being grateful that I can leave and wondering how long before I might be in such a home and unable to leave.

When I’m making my calculation of how often to go and for how long, I think of her providing total care for me until I was out of infancy and then continuing to support me and my family until she had nothing left to offer. Surely that’s a debt I should repay—or better still never calculate how much I should repay but be there with her whenever I can.

But for now it’s an hour a week—based on……?

Richard Smith was the editor of The BMJ until 2004.