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Education  |   April 2012
A Certain Amount of Planning
Author Affiliations & Notes
  • Thomas J. Poulton, M.D.
    *
  • *The Foster School of Medicine at Texas Tech University, and El Paso Children's Hospital, El Paso, Texas.
Article Information
Education / Central and Peripheral Nervous Systems / Education / CPD / Gastrointestinal and Hepatic Systems / Geriatric Anesthesia / Pediatric Anesthesia / Radiological and Other Imaging / Respiratory System / Technology / Equipment / Monitoring / Quality Improvement
Education   |   April 2012
A Certain Amount of Planning
Anesthesiology 4 2012, Vol.116, 962-964. doi:10.1097/ALN.0b013e318242357e
Anesthesiology 4 2012, Vol.116, 962-964. doi:10.1097/ALN.0b013e318242357e
A man is not old until regrets take the place of dreams. 
EACH OF US, we are told, is capable of more than we can imagine. Maybe even more than anyone else can imagine. Dreams—hopes and beliefs for tomorrow—accomplish the impossible. Al was 84 years old when he died yesterday. World War II veteran (got seasick standing watch in a crow's nest 80 feet above the main deck, vomited on someone standing fire watch below). Master woodworker (he's the guy who made the hand-turned walnut baptismal font and those soaring chandeliers for the church sanctuary). Retired contracts administrator for Goodyear (kept all eight of his five-year service pins neatly lined up in a small box in the top drawer of his dresser). Cantankerous neighbor (“biggest jerk in Jackson County” according to a guy down the street who may have been in a position to know).
He also believed in planning. Forty years ago when I was courting his daughter, he suddenly asked me if I plan ahead. “Yes, sir, I try.”“Good,” he paused, “a certain amount of planning is essential to success.” That ended the discussion, but I observed over the years that he did  plan. He retired on schedule at 65 years, and contentedly enjoyed the next 15 years gently antagonizing the neighbors and puttering in the wood shop, always planning the next project carefully before executing it.
Then, at age 80, it became apparent that Al had dementia. Losses followed. He lost his short-term memory and then, when he hit another car, lost his temper, and tried to hit a pedestrian, he lost his driver's license. He was moved into a secure assisted living facility and wore an ankle bracelet that alerted staff if he approached a door. He likened being there to being an inmate in a prison, asserting repeatedly that he did not know why he needed to live there, but always quickly adding, “but the food's great here—we get ice cream every night—and they are nice to us. I don't have any complaints.”
He never remembered the reason his driver's license was withdrawn and grieved painfully for his lost freedom, asking every week why he couldn't have his car and his license back. “Because the doctors say it's not safe for you to drive” never satisfied him for more than a few minutes. Then the questions, and our efforts to distract him and turn his attention to happier matters, resumed.
His daily life otherwise became calm and strangely orderly. He both charmed and disturbed nurses on medication rounds when he cheerfully swallowed the proffered pill: “Thanks, dear, is this my cyanide capsule?”
A month ago, Al developed cholestatic jaundice related to a previously unknown tumor. He felt ill and we talked about options. He reiterated that he wanted no medical interventions and realized that he was dying. “None of us lives forever. It's okay. I've had a good life. I just don't understand why I can't drive. I just want to drive around here, short trips to the store, things like that. Nothing big.”
A week ago, he called us and let us know that he had an urgent need for $300. “But Al, you live in the assisted living facility; you don't need cash there—there's nowhere to spend it.” He grew irate. “It's my money and I need it because I say I need it!”“We'll be down in two days, Al. We'll work it out then, okay?”
We got the call from the nursing director the next afternoon. “Al is gone—we don't know where he is, but someone drove away with him almost two hours ago. Al asked a new employee to let him sit in one of the rockers on the front porch. He no sooner got out there than a dark car pulled up and he jumped up and practically ran to it. They were gone in seconds.”
Ten minutes later, as we finished packing our car, she called back. “Al just walked in. Some other old guy who looks worse than he does brought him inside, then drove off. He's thin on details, but he is smiling like a Cheshire cat. He has returned as a hero, here, it appears. With the exception of his wife, the other residents are smiling more than usual, too. His wife is threatening to kick him. In the shins.”
I asked to talk with him about his day. “It's really been a good day. I called my old friend Ned and we took a drive to look at buying a car. First I've seen him in years. We had a good time.” I asked how he pulled that off and he paused. Slowly, he admitted that he couldn't really remember how he did it, but repeated that he needed a car and they almost got one for him. His voice brightened: “Planning!!” he exclaimed, chuckling. I asked for more details, but his voice trailed off, not evasive, but unsure again.
The next day as I prepared his clothing for the laundry, I saw that his shirt from the day before was stained. I looked his way but asked nothing. He understood. “I threw up in Ned's car. I was really too sick to take that trip, but I just am glad I did it. Ned got mad, though. He says no more trips.” I nodded but kept working on the laundry. I found a piece of paper in his jeans pocket. There it was—Al's escape, planned step by step:
The list was crafted in three different inks, wrinkled, fingerprinted, and stained, as beloved as any velveteen rabbit, to be sure. A certain amount of planning is essential to success.
Al gave me another look, then slowly said, “I was way too sick for that trip but it was good. I got so short of breath at the car place that Ned thought I was dying. I thought so, too. I don't remember how we did it, but it was good.” He smiled very weakly and very briefly, then went to bed. He was so very old in some ways, but he had no regrets. None at all.