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Lessons in Dying Well

turns giving their sister regular respite. Peggy Peltier continued to enjoy a busy social life, accepting rides to weekly prayer meetings and welcoming friends, former students, and church members into her home. A niece and nephew delivered her groceries weekly. A cousin who is a physical therapist also visited regularly and helped provide care.

"I don't know what we would have done without our family visits of grands and great-grands," says Deborah Peltier. An associate professor ofmedicine at DMS, she credits her mother's cheerfulness as a tremendous asset. It drew friends to come visit when she could no longer go out; even after her mother moved to the nursing home, she remained cheerful, Peltier says. "Cheerful is a good kind of demented to be," she chuckles. "It's easier on your caregivers."

When Peggy Peltier entered the nursing home, all four siblings were comfortable with their mother's advance directive declining intensive medical intervention. She was in the nursing home for three years. The winter she was 94, she caught the flu. There was no ambulance, no hospitalization, no ventilator. She was kept comfortable at the nursing home. It was there, 10 hours after her diagnosis, that she died, with Mary at her bedside.

Participating in her mother's care during the last decade of her life reinforced for Deborah Peltier the importance of civility. "A parent will die, but sisters remain," she says. Knowing that her children would maintain good relationships after her death "is what my mother would have wanted," she adds. Peltier is grateful not only that she could help care for the parent who had supported her through college and medical school, but also for the lessons she learned as her mother's health declined—lessons she now applies daily in her practice of geriatrics.

After spending the first part of her career as a psychiatrist, Peltier completed a

Deborah Peltier's mother cross-country skied into her eighties, until a series of strokes finally slowed her down. Even then, she was able to stay in her own home.

geriatrics fellowship at Dartmouth. She has now taught geriatrics at DMS for almost 20 years and is currently the director of the geriatrics and ambulatory-care clerkship. She also works at the VAMedical Center in White River Junction, Vt., in a new home-care program. "It's a delight," she says of the time she spends visiting elderly patients in their homes. She often shares her mother's story with new patients and their family members; she finds that it both breaks the ice and introduces many of the practical issues involved in end-of-life caregiving.

Peltier says she learns much more from a home visit than from an appointment at the clinic. A home visit provides cues for questions—about family photos on the wall, for instance—whose answers offer insight into the patient's past experiences and current cognitive capabilities. Home

visits also allow Peltier to find out who shovels the walk, what's in the fridge, and how far it is from the bedroom to the bathroom. She has a chance to ask caregivers (often spouses who themselves are aging) if their shoulders hurt, if their spirits are sagging, if they are getting adequate medical care.

As Peltier knows from her own experience, providing around-the-clock, live-in care to even a cheerful elderly person is physically and emotionally demanding for a healthy, middle-aged child. It is perforcemuchmore difficult for an elderly spouse. So she realizes that aging patients and their aging spouses can't go it alone. She and her team—which includes a nurse, a social worker, a chaplain, and occupational and physical therapists—assess the depth and breadth of support available to each patient and arrange for more help as needed.

Peltier says her practice is richer since hermother's death. She feels closer to her patients since witnessing her mother's dementia—what Peltier calls "death by inches"—and seeing how it affects a loved one's personality and challenges relationships. "I'm more compassionate," she says. "I know how hard it can be, even with everyone wanting it to go in the same direction. It's not the death part that's so bad," she says. "It's the getting there."

Words they understand

Dr. Katherine Little's parents had signed up to live at Wake Robin, a continuing-care community in Shelburne, Vt., even before it was built. They were in their sixties, forward-thinking, and planning for retirement and eventual old age after careers that had evolved into a commuter marriage: Katie Little's mother had been a professor of social work at the University of Connecticut, and her father a professor of political science at the University of Vermont (UVM). Both had signed living wills many years earlier, and everyone in

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Dartmouth Medical SchoolDartmouth-Hitchcock Medical CenterWhite River Junction VAMCNorris Cotton Cancer CenterDartmouth College