Dementia Nights

Small Aftershocks

Nothing dramatic to report - mainly the aftereffects of the Medicaid transition still rumbling through the landscape.  On Wednesday's visit there were the usual signs that he's getting worse - speech gets progressively less coherent, people get progressively more conflated.  The borders between objects are coming down.  I showed him his new electric razor and he expressed mild interest and then said he had something better and handed me one of the television remotes.  He showed me how you can press the buttons and affect what's on the screen.  This, of course, explains why the television is continually getting mis-tuned.  I'd be happier if the aides could come in and re-set it - ideally to a baseball game - but they clearly don't know how, or don't care, or both.

E would have done it better but she's gone.  Except that she isn't.  She visited him on Wednesday and again on Thursday - and, seeing the condition he's in and the way the aides neglect him, did what anyone would do.  She jumped in and bathed him and helped him shave and changed his clothes.  As soon as I heard about it I had to intervene.  Only the Medicaid aides are allowed to perform aide services.  A civilian like me could help out.  But if another aide does it, that breaks the Medicaid rules and we lose the coverage.  A shame, but that's the system I've got to live in.  E wasn't pleased.  She called me this morning and told me all about what she'd seen of the awful condition of elderly people who had Medicaid coverage - soiled clothing and roaches on the floor "and the women don't care.  But I know how it is," she added.  "You're trying to save some money.  We've all gotta do that."  None of this was really helpful.  She told me again that she's a responsible person and the proof is she owns a house.  I told her again that I don't own a house and probably never will because I can't afford one.  She got quiet all of a sudden and stayed that way.

A few years ago she got my father involved in some sort of legal guardianship for her son.  This requires that he sign court papers every year.  I mentioned to her that he's no longer able to write his signature.  Note to self - tell the family lawyer about that, too.

Apart from all that, the machine is running, more or less.  There was a new aide Wednesday night that I liked - she seemed to be alive, and actually sat at the dinner table with us and joined in the conversation, and he asked her questions and listened to her answers.  He said later that she wasn't any good, but that could be the hangover effect from E's visit.  Unfortunately, the new aide turned out to be temporary, and judging by his phone comments, it sounds like we've gone back to the Night of the Living Dead Home Health Care Workers... 

We'll see how it all shakes out.  It could be that, apart from the human drama, we're making progress - Medicaid is in place, we've been through the staffing changes, he's got 24-hour coverage (it's amazing to think about this but a few months ago, he didn't), he has a gerontologist, there's a care manager overseeing everything... At the beginning of the year, all those things were goals, and we've achieved them.  So that's something.  The overall trend is downward, of course.  But then, it always was.

Am thinking at the moment less of myself than of Shu, whose mother went through surgery for a melanoma yesterday.  I hope that went well and I'll be looking for her next post.  On the surface, the situation sounds similar to what we went through with my father in May.  I hope in her case the outcome is better.  As, of course, it could be.  That's the thing with Alzheimer's - it's always the same, and it's always different.

As long as you remember that, you'll be OK.

The Alan Ladies

Sorry for the long silence.  What can I say?  Entropy is hard work.  It's not like it just happens by itself.

Quick notes on what's been going on...

We're done with E.  Got a call from M late yesterday afternoon, after she'd talked with several of her CASA/Medicaid contacts.  It turns out my father doesn't qualify for 12-hour shifts.  He doesn't meet the medical standard (for example, he's not incontinent, at least not yet).  I'd suggested to E that she consider working a 24-hour shift once or twice a week, but she can't - she says, legitimately, that she has a 15 year-old son at home and needs to be there.  Can't argue with that.  So it's over.  I called her right after I'd heard from M and broke the news.  E wasn't too distressed - she'd already lined up a new job through her old agency.  That's a change.  In the couple of weeks before there were multiple conversations with her, all of them more or less emotional.  She'd report on her progress through the Medicaid review, and lean on me to lean on M to get the new M-11Q filed.  M and I had our sidebars about how best to manage the application process.  And then it's over.  Three weeks later and we're all moving on.  That's the way things work. Taking the long view, you might even say that it was a relatively smooth transition.  And you'd be right.  But you'd also be wrong.

How will my father take it?  Badly, of course - except that I'm not going to tell him in so many words.  I'll let her fade away.  It doesn't help that she insists on visiting him.  She's done it several times and will stop by again tomorrow.  I was on the verge of calling it off but decided not to.  I'm hoping that she'll get busy enough with her new client that she just won't be able to stop by.

It's not that I want to be harsh about it but he's locked in E obsession.  Every night on the phone he goes on for at least a half an hour, sometimes a full hour, about how wonderful E is and how much she's meant to us and how wonderful she'd be working in my business - can I hire her for my business?  I tell him we're working on it.  His fixation on E is understandable, but the result is that he won't accept any of the new aides.  He slipped once and referred to them as "the Alan ladies."  He's extremely angry and he's decided - accurately, it should be noted - that I'm the one to blame.

In his defense, the new aides are a pretty scurvy lot.  I've met a couple of them.  They're harsh and authoritarian and more likely to kick cats than to engage with humans.  Good enough for government work, in other words.  And what did I expect they'd be?  M and I are trying to work with the situation but reality gets in the way - the agency doesn't have an infinite supply and if we keep firing them, eventually we're going to run out.  We did manage to get rid of Monday's Aide - the one that couldn't read prescription labels.  Over the weekend we had a near miss - I got a call late Friday night from the aide on the Thursday shift, accusing the Friday aide of stealing cash.  The agency called them both in and had a hearing, which ended with an acquittal when the missing cash turned up (they said) in my father's pants pocket.  We're keeping them both on for now (see "not an infinite supply," above) and trying to figure out how the household cash supply will work.

In fact, the only decent help I'm getting is from the cat sitter, Tattoo Guy.  Tattoo Guy, it turns out, used to work in human medicine - he was a technician.  He has a background in Alzheimer's and knows what to look for.  He also knows how to interact with my father - comes in and embraces him and picks him up off his feet.  That's exactly what he needs - warmth.  I'd take warmth over skill.  So I've asked Tattoo Guy to keep an eye on things and let me know what he's seeing.  Frankly, the quality of care I get from Riverside Animal Medical Center is so much better than anything I get from the geriatric care establishment that if I could have them take over my father's case, I'd do it in a heartbeat.   I actually asked Tattoo Guy's supervisor, M(cats) about it.  I was only half joking.  She told me they get that question a lot and if she could replace her own physician with her veterinarian, she would.

The other really decent conversation I had was with the Partners in Care collection agency.  Short version of a long story: You remember that my lawyers told me that I could withhold payments from Partners, and Partners would be reimbursed directly by Medicaid?  The lawyers were wrong.  I found that out by reviewing Medicaid reimbursement materials that the lawyers sent me themselves.  This is right up there with the time they didn't bother to tell me about the oh, I don't know, 300 percent increase in the Medicaid asset ceiling.  Enough.  Given that they hadn't memorialized anything to Partners - apparently they don't write letters, they just leave voicemails - and given that I was hanging out there with unpaid bills that go back to March so my credit rating was about to get hosed - I decided the best thing would be to pay the man.  So I'm doing that.  Another round of asset sales and then I'm moving the checks through (without busting the Medicaid limits, of course).  I suppose my willingness to pay - instantly - made for a better dialogue with Collection People.  Still, professionalism is professionalism.  Noted for the record. 

Meanwhile, I phone my father every night and get hammered about E and beyond that, I try to figure out what he's talking about.  In the past couple of weeks he's slid dramatically - whole chunks of the conversation are now completely incoherent.  I don't just mean that they're irrational or distorted.  I mean they consist of nonsense sounds.  There aren't any words there.  Then the words come back but the cognition's shot.  Last Thursday he went on for 20 minutes about a bridge in the second bedroom that went to the East Side and that was in danger of falling - he'd gone downstairs by himself to get the handyman (did he?  I don't think so) but no one would take him seriously.   What was he talking about?  It might have been a windowshade, but I'm not sure.  Last night he talked endlessly (and recursively) about the dark, threatening weather (it was night).  He's done that before but the sense of upset is much deeper now.

I think the loss of E really damaged him.  I'm not sure - a lot of the progression is steady and organic.  But of course there have been lurches, too, and sometimes stress brings them on.  You hear those stories about people with Alzheimer's - and elderly people in general - who are never the same after they're moved out of their apartments and put in homes.  This isn't quite the same thing, but it might be similar.

At the same time - and maybe as a result - I notice that I'm beginning to detach.  I know I've talked a lot about detachment - all those Zen riffs, for example, which were nice enough.  But I have to admit that at some basic gut level, I was still hugely caught up in trying to make my father happy.  Not just comfortable - happy.  That was the source of a lot of tension. And last week it broke.  It dawned on me - also at a gut level - in the middle of one of those long telephone monologues - that I can't make him happy anymore, because he's not really capable of happiness anymore.  There's nothing there to work with - well, there are some things, but there's not a coherent set of emotions that you can address and cultivate over time.  There are impulses, but impulses aren't the same.  All you can do is let them play out and engage where you can and try to recognize the limits. 

I don't know - maybe I'm rationalizing and I've actually made him unhappy.  And maybe I would have done better to keep him with E and just let the assets burn.  And maybe I'm only in it for the money - I make sure to look at that possibility fairly often, because it might be true, and also if you don't, there's a big temptation to give yourself The Martyr's Trophy when maybe all you're trying to do is take care of your own interests.

But even so (he said, going in circles) - E would have burned out the brokerage account in eight months and after that there's a trust that, if you break it, would have kept him going for a couple of years.  And if he lives longer than that?  Seems unlikely but who can say? There's the problem again - no good answers.  So maybe I'm just picking this set of bad options from among several sets of bad options.  Or have I said that before?

Under these circumstances, you realize - or more accurately, your body tells you - that things are just the way they are, and none of your thinking or gyrating is going to make much of a difference.  Once you realize (or your body tells you) that, you break.  But that's a good thing - sort of liberating in its own way.  Nothing to be tense about because there's really nothing to aim for.  If you're wrong, you're wrong - and you probably are.

Might as well continue on for the ride.

Birthday Notes

He's 86.

I could make a thin joke about that ("eight-six him"), but I'll let it pass.  As I've said before, those of you who work the territory will understand.

He enjoyed dinner and his gifts more than I'd expected.  The photography books went over especially well.  He liked the Andreas Feininger better than the Berenice Abbot, which makes sense when you think about it - Abbot is more formal and architectural, Feininger is more emotional and shoots for effect (lots of long-lens work) and shows more people.  It was interesting to see what he could and couldn't interpret.  On the one hand he was able, with very little prompting, to remember neighborhoods and details of city life (he thought it was odd, and it is, that the Feininger photographs don't show more people in uniform).  On the other hand, he saw a building facade as a cliff, and a ship's rigging covered in thick ice as a pair of horses.  The trend continues - he sees things but can't roll up to the concept of what they are.  The past is a little more coherent - not much, but it's something.

Other distortions are creeping in - or more accurately, creeping back.  In addition to his leaving the cell phone number in the sun, he's beginning to do odd things with his hands and fingers again.  He began pulling on the little finger on his left hand and complaining that something was wrong with it.  I thought he'd banged it but apparently not - instead he thinks it's out of alignment ("it was out like this," he said).  That's another throwback to the days immediately after his surgery, when he was obsessed with his hands and fingers, and disoriented about how they were arranged.  It may also be related to the thigh massaging and hand positioning that he does when he's trying to affect the TV image.  Again - it seems as though the days after the surgery were the preview, and this is now the regular programming.

He was able to make out two of the three words in the Peanuts card - "happy" and "happier" but not "happiest."  He got a card in the mail from my mother-in-law but couldn't remember who she was, and I couldn't fully explain it because now he doesn't remember who my wife is - she's now part of the wife plus daughters/cats roll-up known as "the girls."  As in, "how are the girls - are they home from work?"

The disorientation now extends to E, at least a little.  At times he was still obsessed with her, but at others he seemed unclear as to who she was.  And then he asked, "Is she working for your company now?"  Meaning, if she isn't working for him, is she working for me?  I said yes, and he seemed relieved - as though she'd gone on to something good.  At a couple of other points I told him again that we were trying to get her approved by the government and he talked about that a little and then lost the thread.

Part of me (the part that thinks denial and avoidance are really useful tools) would like to see this as an opportunity - he'll forget about E and get more comfortable with the new aides.  But of course that's not going to work, and it's not the right answer, either.  We need E back because she's better on the merits.  I spent part of the evening, as usual, trying to take note of things.  The results weren't good.  From my e-mail to M, sent late last night via Blackberry from a downtown number 2 train:

[Monday's Aide] is dangerously incompetent and needs to be removed.

First example - she said "that other girl" (E) told her about some medication he was supposed to take once a week, but "I never heard of a once a week medication so I didn't give it to him." She brought out two prescription bottles. The first was for Vitamin D and was clearly marked "once a week." I pointed this out to her and she said, "oh, once a week - I'll give it to him tomorrow." The other was for post-op codeine and should only be given as needed, but she didn't seem aware of this. In addition - the Vitamin D prescription had only one pill remaining. It's marked for two refills but she didn't register this and showed no inclination to act on it.

Second example - the apartment was extremely hot and stuffy. She said she'd been ordered not to open windows because of the cats. I told her to check on the air conditioners. She said she didn't know how to use them. I checked them and found they were both on fan settings. I switched them to cool settings and everything was fine inside of five minutes. Please note that the air conditioners work via simple dial and button controls - there's nothing complicated or unusual about them.

She's clearly not able to read and this is causing multiple risks to my father's health and safety.

Please feel free to share this message with [the new agency] or elsewhere as you see fit.

So that's not going to work out.

Like I said, keep turning them over...

I have to think there are better people out there.  If I don't, I'm going to be depressed.  On balance, E would seem to be the best answer.  I'll stay hopeful that M can succeed with that.

Meantime, I'm glad - seriously glad - that he got something out of his birthday. 

Now, time to see about navigating him through another year.

(This) Morning in America

Like I was saying... I really don't want to get political.  But this morning, a little after Amtrak 912 had a catastrophic power failure and died, it occurred to me that I'm really living out the Republican vision. 

I mean, why, I asked myself... as I was climbing down the train stairs onto the tracks near Aberdeen, lugging my father's birthday presents... and getting ready to climb up onto the rescue train... and listening carefully to the conductors' instructions about not touching both trains at once because if you did you might complete the circuit between them and that would be bad...  and settling in on the rescue train, which had come up from Miami and which looked like a bus on rails, full of half-awake, desperate-looking people... and resuming my trip to New York so I can look in on the home healthcare establishment I've put together myself out of bits and pieces I found lying around the city... why would you have it any other way?  Why would you fund public transportation? (side note: this is the second Amtrak power failure I've dealt with in two months - the last time I was on the rescue train, this time I was rescued).  And why would you create a healthcare system that was coherent and systematic and filled with trained, motivated people?  And why would you want caregivers to give up the rich, rewarding experience of running the current, ad-hoc healthcare establishment hands-on in every minute detail, and leave their loved ones in the hands of, you know, Big Government?  I mean, if all of that happened, then we wouldn't be self-reliant, now, would we?

It's wonderful to find out that you're trapped in somebody else's myth.   

Sorry.  I want to be broadminded but sometimes it gets to you.

Now back to our regular programming - uptown for the birthday festivities and to meet Monday's Aide (plus 1, not minus 1). 

A report will follow.

Celebrating September 11

Don't get your Homeland Security shorts in a knot - it's his birthday.

Always a big day in our family.

Hell of a party they gave him for his 79th.

Thursday he'll be 86.  When I have dinner with him tomorrow night I'll try to make it as celebrational as I can.  It's hard because he's obsessed with E and can't stay focused on the fact that it's his birthday.  Even before the E crisis hit, it was difficult - I'd mention to him that his birthday was coming up and he'd be amazed, then forget about it 'til the next time I brought it up.

In the old days it was easy to buy presents for him - books, always books.  Now he can't read but I don't want to break the tradition.  Last year I started buying him books that were mainly photography.  I'll do the same this year - I bought him collections of photographs of New York in the '30s and '40s by Berenice Abbot and Andreas Feininger.  We'll see if he makes a connection with them but I'm not optimistic.

Cards are a challenge, too.  We used to get elaborate with them and add lots of customized messages but now I try to find something simple and familiar, with pictures and not too many words.  Peanuts cards always work well.

There's also an electric razor.  A couple of weeks ago I noticed he was beginning to grow a Mennonite beard - not on the jawline but on the throat (modified Mennonite?)  He said he was afraid to shave there because there were blood vessels.  Thankfully he has a well developed sense of danger.  It's past time to shift him over to electric so I'll use the occasion as... well, as an occasion.

The gifts aren't the important thing, of course - but the changes are a way of marking where we are.  The important thing is spending the time - and also trying to gauge his reaction.  How much is getting across?  I get the feeling that his experience of his birthday is going to be pretty tenuous this year.  But who knows where he'll be next year?

I guess birthdays are for taking stock, so we'll try. 

Monday's Aide

Monday's aide was a marginal improvement - marginal being the operative word.  According to M:

The caliber of home attendants is appalling.  If [Friday's aide] on a scale of 1 - 10 was minus 1, [Monday's aide] is 1.  She can read somewhat and I am trying to help her understand she cannot accept what Dad says and needs to take charge of his ADLs [Activities of Daily Living].  Basic stuff.  I just don't know how these people get certified.

Meanwhile, E is making quick progress through the system - so far.  Her certifications are relatively advanced and her recommendations are good.  That, plus judicious use of M's connections in the bureaucracy, mean we may be able to get her back on the case in a couple of weeks, as opposed to a couple of months.  There are still barriers, though.  E can't work 24-hour shifts (she's widowed and has a teenage son at home) and right now that's what we're approved for.  The new agency thinks it'll be easy to shift over to split 12's, but M is less optimistic.  We'll have to wait and see.

I hope we can find a way to get her back on the job, because my father has been round the bend ever since last Thursday.  Every day through yesterday morning, there were multiple phone calls, some as long as an hour, where he ran over and over through a repeating loop - how good E is, how we need her back, how terrible the new people are...  I couldn't argue with any of it but since he doesn't have a sense of time anymore, it was essentially useless for me to tell him that we were working on it and he'd have to be patient.  But I told him that anyway.  And he'd ask, "Is there anything I can do?  Because E is really important to us", and then he'd be off on the loop again.

Yesterday E went to visit him.  She really seems to miss him and to want the job back.  He was much better afterward - or at least more relaxed.  He's now convinced she's back working for him, and since his time sense is so bad, we may be able to play that out for a while.  But the additional effect of the relaxation was that his cognition fell apart.  It was as though only the anxiety was keeping it together.  Last night's phone conversation was barely comprehensible.  The main thing I was able to get out of it was that he's now taking the piece of paper with my phone number on it and leaving it in the sun so it'll warm up and dial my telephone.  That's a throwback to the jar of seashells.  I had the feeling back then that we were seeing a preview of his future and now it seems that way.

Tomorrow I'll get to meet Monday's Aide (the one that's a plus 1, not a minus 1) and try (again) to get a handle on things...

Friday's Aide

From what I've heard, Friday's aide wasn't full of grace or fair of face or anything like that.

M, by phone: "She doesn't speak English and she can't read.  If there was an emergency I don't think she'd be able to call either of us.  She'd be perfect for someone with dementia who was bedridden and comatose."

Well, that's great.  They sent us someone to care for a generic demented person.  As opposed to my father, who's not bedridden and needs interaction and in most respects is highly specific.

My reply: "Fine.  Let's get rid of her and keep turning them over 'til we get someone that's right."

Later in the day a call with my father.  His description is a bit incoherent but what I was able to get out of it is that at some point the non-reading, non-phoning aide flung open a window and leaned halfway out of it to get some air.  Twelfth-floor window, that would be. 

I sent an e-mail to M: "New standing order.  Windows to remain closed at all times.  Because if a life form goes out the window - human, cat, whatever - I'm going to have somebody's head on a pike."

M is working overtime, trying to get us a decent aide and trying to get CASA and the agency to expedite E's review.  Early Friday they said it'd take six to eight weeks.  Late in the day M was guardedly optimistic that we could do better than that.

A week ago when I was getting ready to fire M, I wouldn't have bet that the big new urgency would be, how quickly can we get her back in?  But there we are.

The phone calls with my father are painful at the moment.  He goes on and on and on about how important E is, and how we need her to work for us, and how she's better than the guys (sic) that are there now, and what can he do to help get her back in?  I tell him that we're working hard on it and M knows how the system works, and he says that that's good because he thinks M is a great guy and he likes working with him (her).  Then he tells me how important E is, and we go over it all again...

I suppose it's possible that in a few weeks he won't remember E, but I'm not betting on it.  So tomorrow morning we'll pick up the effort and see what we can get done this week.

A slightly mangled process, this has been.  Which is what you get when you're in a world of bad outcomes.

Or Not the End of E...

The transition went smoothly until it actually happened.

Partly my fault, though it's also just the way things are.  I decided last night not to tell my father about any of the changes.  I was hoping... what was I hoping?  He's having a hard time recognizing people and keeping track of events and changes, so maybe... well, in a best case, he won't notice that E is gone.  Yes, admitted - I can think magically along with the best of them.  More realistically, he'll notice but roll with it and adjust quickly and not mind too much that a new aide was in place.  And at least he'll have a calm night before the brief (it'll be brief, right?) agitation.  And maybe E would be sensible and not mention she'd be leaving.  And maybe M would be there ahead of the new aide and talk everybody through it - saying that this is just temporary, it's something else that Dr. R wants us to do...

Nice plan.  Didn't work.  I should have remembered two things.  One, my father gets agitated when you have to take him for a vitamin shot, let alone swapping out his aide of five years.  Two, however bad his cognition is, it suddenly snaps into focus when there's an emotional charge.  Which there was.

The phone calls started a little before 8:30 this morning.  My phone had been off and I kept it off for a while.  I was hoping M would get there and be able to smooth things out.  Then I got the distressed voicemail from M...

I called over there around 10 a.m.  Talked with M first.  Had a brief visual impression of a mushroom cloud rising over West End Avenue.  Then listened.  The story: my father wildly upset, totally focused on E, not understanding why E is being taken away.  He insists we keep her.  E in tears, not wanting to leave, wanting to keep the job, telling M she'll get on the Medicaid rolls so she can stay (she couldn't have mentioned this during the six months she's knows about the Medicaid review process?) The new aide trying to get briefed on the household routine, which is of limited value to her and to us because she's only covering for today.  That's rich.  The agency is picking up a dementia case where the patient can't deal with changes in routine, so they start us out with a one-day temp...

I try to sit on my blood pressure and get on the phone with my father.  I tell him as clearly as I can - in as much detail as I think he can handle - that we're making these changes so that the government will pay for the help he needs.  And that's a good thing but also a difficult thing, because the government is hard to work with - you know that from all the way back when you were in the Coast Guard.  And the problem right now is that the government will only work with people it approves of, and this new person is one of those people, but right now, E isn't.  So this new person has to cover until E gets approved by the government.  But as soon as we can get E approved, we'll bring her back in...

And I mean that sincerely.  Because I've decided on the fly, in the course of these conversations, that if two weeks from now he's still insistent on E, let's fold her back in.  I can figure out a way to pay her a supplement on top of the Medicaid wage.  The supplement will be way less than I've been paying.  And at least there'll be a familiar face in his household.  Me, I'd just as soon be done with her, but this isn't about me, it's about him.

So I tell him that.  And then I tell M that.  And then I tell E that.  And E heads off to apply to the new agency.  Plan B.  Why not?

Plan B isn't entirely worked out yet.  There's this complication: right now, the coverage calls for 24-hour shifts.  But E can't work a 24-hour shift, only a 12-hour shift.  We'd been planning to apply for split 12's.  Now there's more reason to, and we'll do it sooner.  But until that's approved, E doesn't fit.  It's an unknown.  I suppose we'll deal with it.  The new aide thinks it's likely we can get the split 12's approved.  We'll see.

A half-hour later M calls back, and that's when I start thinking that - apart from the issues of sentiment and familiarity - there's a really strong case on the merits to keep E in place, and we've got to try to bring it off somehow.  M is calling because I'd written out a page or two of instructions for the new aide.  One of the sections had to do with how to care for the cats.  It talked about feeding them twice a day and cleaning out the litterbox every so often.

The new aide has just refused to do it because she's not allowed to care for animals.  "She can't even touch them," says M.

My vision of the mushroom cloud is replaced by my vision of starving cats.  I take a deep breath.  I say, "That's too bad.  They're therapeutic."

"So I understand," says M. 

"The agency should understand that there's real medical value here."

"That's what people say.  But this is the problem when you start dealing with Medicaid and the agencies.  They have their procedures."

"Can the aide open a can?" I ask

"Excuse me?"

"Can the aide open a can?"  I'm getting worked up.  "Look, we're not talking about having her walk a pit bull.  We're not talking about asking her to be a livery driver.  We're not having her take my father across state lines for immoral purposes.  We're asking her to pull the tab on a can of cat food.  Can she do that? "

"I'll ask," says M.  She stays calm.  She's probably dealt before with family members.

She reports back that the new aide is in fact willing to open a can.  But there are no guarantees about tomorrow's aide.

"OK," I tell her, "then I'm going to have to find a cat sitter."

"What's that?"

"A person who'll come in and take care of the cats.  You've probably dealt with them on other cases."

"I've never had a case with animals before."

I find that astonishing given what I know about the Upper West Side, but I decide to file that thought away.  I tell her we'll all learn about it together.

I call the other M - the one at Riverside Animal Medical Center.  Yes, M - same name, not just the same initial.  For clarity, let's call her M(cats).

M(cats) is the single best person I deal with, about anything, at any time.  She's hugely competent and extremely warm - you walk away from a conversation feeling better, and you don't know how.  Within five minutes she's lined up a sitter.  "There's only one issue," she says.  "He has a lot of body tattoos.  He doesn't know how your father will react to that."

I think for a minute.  My father now routinely reverses the genders of the aides.  Last night, he asked me again about my kids (my cats).  "They're older now - are any of them married?"  Not yet, I told him.  "Boy, I really like that one that came up to visit me when I was in the hospital."  That would be my wife.

How will he react to the guy with the body tattoos?  "Don't take this the wrong way," I say to M(cats), "but the real answer is, no worse than he'll react to anything else."

Cat sitter is now arranged.

Of course, if E was in place, the cats would be fed, no problems.

Then there's a new financial calculation.  The pet sitter costs $15 a day.  That'd buy... what?  Two or three hours' worth of E's supplement, depending on where the billing rate falls out.

Yes, E.  Go jump through the bureaucratic hoops and then we'll welcome you back.

I'm now exhausted and lying low and not trying to think too much about having mangled the whole process.

Or maybe it's just a mangled process.

I'll report more details as it continues to get more mangled.

The End of E

Fired E this morning.  Or laid her off, or whatever the correct term is.

I hate firing people, even when they're annoying and marginally irresponsible and the economic case is clear cut.  Always did, even when I had to fire a lot of people.  You're taking people's livelihood away and that's pretty brutal.  At least I managed to stay on good terms with nearly all of them afterwards.  All except the guy who committed suicide.  People like to tell me that wasn't directly related and I guess it probably wasn't but how do they know?

Firing someone by phone, which I did with E, is particularly bad.  Frankly, it's wrong - you should face people and stand up for what you're doing.  But I live out of state and the new aide is supposed to start Thursday so there wasn't much choice.

I tried to be as clear as I could - I'm sorry about it, it's economic, there's no choice.  Actually it's also performance-based, but that doesn't matter - it was the economics that forced the decision.  Even if she'd been the best aide in creation, I'd still be where I am.  She took it well - or at least professionally.  Said she understood, she was willing to show up on Thursday for a transition day to get the new aide oriented, she'd be available if I needed anything.  Tonight I wrote out a last check, including severance, and a set of instructions for the new aide.  I'll drop them off tomorrow and that'll be that.

I don't think she mentioned anything to my father.  If she did, he didn't remember it enough to bring it up.  That's good - I'd been mainly concerned about her getting upset and vindictive and setting him off in the process.  But he was concerned with other things.  His cognition has gotten even worse in the past few days.  Saturday night he told me he'd discovered a big red and white dog in the apartment, and he had no idea how it'd gotten there.  He's referring to one of the cats.  It's been there since 2000.  Tonight I told him I'd be coming up for dinner and he asked if the kids would be able to join me.  The kids are a combination of my cats - who in his mind have now morphed into children - and my wife.  Then he asked if that guy (me) would be visiting.

It's not just a matter of letting E go.  Lots of transitions at the moment.  Feels like we're getting into a later stage - maybe a late stage, though you can never tell.  But the picture is changing and it'll keep changing.  I'll go up to New York tomorrow and see what it looks like and report back.