Driving advance directives

[Innisfree]

Quote

Lewis Morgenstern has made up his mind. When he turns 65 in four years, he’s going to sign an advance directive for driving.

The directive will say that when his children want him to stop getting behind the wheel, Morgenstern will follow their advice.

 

“I recognize that I might not be able to make the best decision about driving at a certain point, and I want to make it clear I trust my children to take over that responsibility,” said Morgenstern, a professor of neurology, neurosurgery and emergency medicine at the University of Michigan.

 

His wife, 59, intends to sign a similar document at 65.

This is an interesting idea, one step beyond talking with elders or adult children about an issue that usually comes up eventually.

The advance directives lack any enforcement teeth. They also don’t guarantee that workable alternatives to driving exist for impaired seniors. Still, at least they would start the conversation while perhaps plans could be made to minimize the pain of handing over the keys.

I like the idea, and would hope that knowing what an elder had wanted when they were more capable of assessing the dangers of impaired driving would make decisions easier for their kids. 

https://wapo.st/4aX7a0C (no paywall)

[JustEm]

I wish my mom would acknowledge that she shouldn't be driving anymore. Better yet, I wish my dad would acknowledge that she shouldn't be driving anymore. Because if he did and told her that she would likely listen. 

[QueenCat]

Dh is counting on fully self-driving cars by the time it isn't safe for him to drive anymore. 

I figure he's got 20 years for that...

[Bambam]

I am thankful my MIL decided to give up driving when we moved her here. I was leaning highly towards advising her strongly to give it up (she has never been a good driver anyway), but my DH wanted to wait and see if she could make that decision.

Another elderly lady I know decided herself. She knew she was getting physically weaker and her reaction times were not what they once were. So, she would go out and just drive around her neighborhood - during the day when there was very little traffic and pretty sure to have no one home - and try to evaluate whether she could handle an emergency situation. She decided that she was not sure she would have the strength to rapidly turn the wheel should it be needed, so she decided to give up driving. She did keep her car for a couple of years though - so other folks could drive her the places she needed to go. 

I've been helping some elderly ladies, and one thing I had never noticed/realized before, processing time slows down as you get older. Majorly old, major slow down. Definitely not a good thing if driving. 

[YaelAldrich]

I'm laughing because people like that (high powered, smart, driven, used to being in control)  may SAY they will give their freedom up when it's "time", but my in laws and father show me that when the time actually comes, they make every excuse in the book to avoid the loss of control.

I haven't watched my in laws drive but I suspect at least my MIL isn't reacting the war she used to on the road. I *know* my dad's driving has deteriorated and when he's under stress/deadline, he's bordering on being an unsafe driver. Muscle memory counts for a lot while driving but sooner or later the rest of the package can't compensate to make for a safe driver. I fear the day I try to take my dad's keys away from him. 

[Innisfree]

1 minute ago, YaelAldrich said:

I'm laughing because people like that (high powered, smart, driven, used to being in control)  may SAY they will give their freedom up when it's "time", but my in laws and father show me that when the time actually comes, they make every excuse in the book to avoid the loss of control.

Some will react that way, no doubt. I think the point is to inoculate their family members against guilt when it’s time to make the tough decisions, and also to encourage planning ahead.

My father had similar qualities, but did hand over the keys. Some people make rational choices. They’re probably not the ones who most need to undertake this discussion early, but surely normalizing the idea of voluntarily relinquishing the keys is a good thing.

[GoVanGogh]

I am getting there myself due to Parkinson’s. I can’t drive more than 10-15 miles from home and can’t drive on the interstate. I don’t think a lot of people are aware that balance issues are just as bad, if not worse, while in a moving vehicle. It isn’t so much my own driving but seeing other vehicles weaving in and out of traffic at high rates of speed (even on the other side of the road) is too much for my brain to process and it sends my brain/head toppling. I always thought I would turn over my keys when need be, but there is such a loss of independence, even at my early stage of Parkinson’s. I haven’t been able to drive myself to my friends home or to my favorite shopping places for several years now. My DH was diagnosed with cancer last year and I can’t drive him to the oncologist. He ended up hospitalized late at night due to complications from his cancer treatments and I totally understand why people are so resistant to turn over their car keys. It is one thing to not be able to drive to the grocery store. But to not be able to drive your spouse to the ER or follow an ambulance to the hospital is quite another. There is the loss of independence and then there is totally stranded at midnight. I can see where having a plan on paper sounds good (I will turn over the keys at this point…), but then when things happen it just isn’t the same. 

[Carol in Cal.]

1 hour ago, QueenCat said:

Dh is counting on fully self-driving cars by the time it isn't safe for him to drive anymore. 

I figure he's got 20 years for that...

Me, too.

[Annie G]

Even if the guy in the article resists when his kids say it’s time for him to stop driving, I give him credit for trying. For saying that he trusts his kids to make the hard decision.   I spent years trying to get my father to stop driving, and every time we did a group sibling intervention w dad, my sibs backed off and made me look like the bad guy. We were finally able to do it last year, but dad is most angry with me about it even though I had finally stood my ground w sibs and made them lead the last meeting where we took his keys away. 

A few months before FIL passed he drove me to the cemetery to ‘visit’ MIL. He specifically asked if I thought his driving was ok (it was excellent) and told me he would be devastated to not ever drive again, but asked me to tell him if I ever thought he needed to stop. That was real love. Driving meant everything to that man but he didn’t want to put us through the pain of dealing w him ever hurting himself or someone else because he was too selfish about wanting to keep his independence.

[City Mouse]

People can say what they plan to do regarding driving at a certain age or stage, but when dementia sets in, those plans go out the window. My father decided to give up driving all on his own when he was 78 after getting lost in a familiar are one time. Less than 2 years later, the keys and the car had to be hidden from him or he would try to drive. 
I think it is great for people to plan ahead, but I don’t think any document will make a difference in a person with dementia.

[Innisfree]

20 minutes ago, City Mouse said:

I don’t think any document will make a difference in a person with dementia.

Completely agree. It won’t make any difference to the person with dementia. Would it make a difference to the adult kids, though? Do you think that hiding the keys and the car was easier because you knew that when he was able to make rational decisions, he recognized that necessity? 

[YaelAldrich]

1 hour ago, Innisfree said:

Completely agree. It won’t make any difference to the person with dementia. Would it make a difference to the adult kids, though? Do you think that hiding the keys and the car was easier because you knew that when he was able to make rational decisions, he recognized that necessity? 

I don't feel guilt about having to tell my father at that time that he won't be able to drive. I'm scared and worried NOW how that conversation will go, but I don't feel guilt. I'm not sure why there would be guilt.

We all have our blind spots, rational or irrational people we be. Loved ones (or the law) might have to burst our bubbles all throughout our lives, probably more towards the end of our lives.

 

ETA Maybe this is because I'm the only one left in my nuclear family since my mother and sister have passed away. So I know it's only me at the end of the day taking care of my dad. 

Edited January 21 by YaelAldrich

[East Coast Sue]

1 hour ago, City Mouse said:

People can say what they plan to do regarding driving at a certain age or stage, but when dementia sets in, those plans go out the window. My father decided to give up driving all on his own when he was 78 after getting lost in a familiar are one time. Less than 2 years later, the keys and the car had to be hidden from him or he would try to drive. 
I think it is great for people to plan ahead, but I don’t think any document will make a difference in a person with dementia.

I’m dealing with this situation (my elderly father) and it’s very difficult. His neurologist helped a great deal by telling him that he had accomplished something very rare- completed 65+ years with no accidents- then insisted that he could not drive again but restated what an amazing driving record he’d earned. 

[Laura Corin]

2 hours ago, Innisfree said:

Completely agree. It won’t make any difference to the person with dementia. Would it make a difference to the adult kids, though? Do you think that hiding the keys and the car was easier because you knew that when he was able to make rational decisions, he recognized that necessity? 

And there are many people with reduced reaction times and physical strength who don't have dementia.  A document may help in reminding them of their good intentions. 

[Melissa in Australia]

Here they have just introduced compulsory driving tests for people over 75 . They have to take the driving test every 2 years. It isn't the full driving test, but the reaction time test part

Edited January 21 by Melissa in Australia

[Innisfree]

6 minutes ago, Melissa in Australia said:

Here they have just introduced compulsory driving tests for people over 75 . They have to take the driving test every 2 years.

I think that’s wise. How do people feel about it?

[City Mouse]

6 hours ago, Innisfree said:

Completely agree. It won’t make any difference to the person with dementia. Would it make a difference to the adult kids, though? Do you think that hiding the keys and the car was easier because you knew that when he was able to make rational decisions, he recognized that necessity? 

Nope, the safety of other people on the road and pedestrians far outweighed my parents desire to drive. Of all the things that I felt guilty about, preventing an unsafe person from driving does not cause me any guilt. I flat out told my mother that if I ever found out that she attempted to drive again that I would call the police and I would contact the state board to get her license suspended. (Long story but she had major vision issues) Then I explained what she would have to do to get it reinstated. She stopped threatening to drive.

The state where my parents lived does have additional steps for renewing a drivers license at age 80. Both had to stop driving several years before 80.

Edited January 21 by City Mouse

[J-rap]

I know my children well enough to know that if they thought my driving was unsafe, they would just outright tell me and also act on it, whatever I thought.

My father drove until he was 96 but self-regulated very well...  stopping freeway/highway driving first, then night driving, then only driving a 6-block radius.

I think an advance directive is fine but it would only be enforced if children decided to follow-through with it, and that can be hard.

[Annie G]

4 hours ago, Innisfree said:

Completely agree. It won’t make any difference to the person with dementia. Would it make a difference to the adult kids, though? Do you think that hiding the keys and the car was easier because you knew that when he was able to make rational decisions, he recognized that necessity? 

It would have made a difference with two of my siblings. One still feels very guilty that we took the keys away. If Dad had talked about this before the cognitive issues set in, I think my sibs would have acted sooner. Sure, we still would have had to force dad not to drive, but my sibs probably would have carried less guilt after.

 

[ScoutTN]

Thankful that both my stepfather and my mom gave up driving voluntarily! Both around age 80. They had already stopped driving on the interstate, at night, downtown, etc.

[Laura Corin]

My mum stopped riding her 125cc motorbike at age 85. She didn't have the strength any longer to reliably pull it onto its stand. I suspect that it was a good time for her to stop due to issues around reaction times too.

If I had tried to force the issue based on a previous document, she would just have said that she had changed her mind. 

I had to force other issues with her where she had previously agreed to measures that she later considered an outrageous infringement of her liberty.  Knowing that she had agreed previously did help me.

[Anne]

My dad is still driving at 94, but only in a fairly limited way.  No freeway or night driving, no long distances.  He also got an iPhone this year and learned how to use Uber so he is prepared for even further reductions.

Anne

[Innisfree]

23 minutes ago, Laura Corin said:

Knowing that she had agreed previously did help me.

I felt better about various decisions I had to make because I knew that my mother would have agreed with me earlier, too.

 

@YaelAldrich “Guilt” might not be the right word for the discomfort of taking away the keys. Maybe it’s a better descriptor for how I felt about moving my mom out of her own longtime home to a place she was safer but less happy. Anyway, I think documents like this might help, but I know they’re not panaceas.

Edited January 21 by Innisfree

[Terabith]

As someone who had my drivers license revoked for being hospitalized for depression (for six months!), honestly it would take a lot for me to tell someone who I wasn't completely certain shouldn't be driving, that they couldn't drive.  

It would be one thing if we lived in an area with functional public transit, but we don't.  It was beyond horrible, and if my in laws hadn't stepped up to drive my family, we wouldn't have been able to send my kids to brick and mortar school.  They were attending a private school at that point, but our public schools don't have functional bus system either, and kids simply don't get to school twice a week or so because the buses simply don't come.  

How are people who cannot drive and don't have public transit to get to medical appointments or to procure food or other necessary items?  There's simply nothing within safe walking distance.  

Edited January 22 by Terabith

[Annie G]

13 minutes ago, Terabith said:

 

How are people who cannot drive and don't have public transit to get to medical appointments or to procure food or other necessary items?  There's simply nothing within safe walking distance.  

In our case, Dad has my sister a few minutes away and she is his primary caretaker, and the other three of us live about an hour away and can help as needed.  But without that, yes it can be an issue. Where Dad lives there is a senior center that can arrange rides to doc appointments and grocery shopping, and he has grocery delivery available. But without family or senior services, it’s a problem for sure.  I think many folks rely on friends if they don’t have family nearby.  

In our case, in addition to loss of ability to drive safely, Dad was not making good decisions. A scammer called him and convinced him to go buy gift cards and give them the numbers, and my sister also found him at a bar chatting up a young girl. Unsafe situations galore!

[wathe]

In my province, senior drivers have to do a senior driver renewal every 2 years, starting at age 80, comprising:

• A vision test.
• A driver record review.
• A 45-minute group education session (GES).
• Two, brief, written (non-computerized) screening exercises.
• Taking note of and then completing any required follow-up items for the MTO driver improvement counselor.

The "screening exercises" are cognitive tests: Clock drawing test and single letter cancellation test.  

It's a pretty good system.  

 

[Terabith]

3 minutes ago, wathe said:

In my province, senior drivers have to do a senior driver renewal every 2 years, starting at age 80, comprising:

• A vision test.
• A driver record review.
• A 45-minute group education session (GES).
• Two, brief, written (non-computerized) screening exercises.
• Taking note of and then completing any required follow-up items for the MTO driver improvement counselor.

The "screening exercises" are cognitive tests: Clock drawing test and single letter cancellation test.  

It's a pretty good system.  

 

Not super relevant here, but I find myself wondering how cognitive tests that feature clock drawing are going to need to change in the next 25 years or so as people who have never really had exposure to analog clocks become eligible for these sorts of tests.  

[KungFuPanda]

My mother is 75 and drives as well as anyone.  She's doing carpool runs to middle school band and sporting events.  She might be younger than me. I think my grandmother stopped driving in her mid eighties.

[wathe]

23 minutes ago, Terabith said:

Not super relevant here, but I find myself wondering how cognitive tests that feature clock drawing are going to need to change in the next 25 years or so as people who have never really had exposure to analog clocks become eligible for these sorts of tests.  

I've had the same thought.   Analog clocks are still plentiful in public spaces here (hospitals, schools, train stations, city hall clock tower etc), but seem to be disappearing in private spaces.  When our kids were toddlers, we realized that we didn't have a single analog clock in the house!  Fixed that with a quick trip to IKEA 🙂 

[Grace Hopper]

29 minutes ago, wathe said:

In my province, senior drivers have to do a senior driver renewal every 2 years, starting at age 80, comprising:

• A vision test.
• A driver record review.
• A 45-minute group education session (GES).
• Two, brief, written (non-computerized) screening exercises.
• Taking note of and then completing any required follow-up items for the MTO driver improvement counselor.

The "screening exercises" are cognitive tests: Clock drawing test and single letter cancellation test.  

It's a pretty good system.  

 

I wish we had screenings like this in place. The best we’ve been able to do is ask the primary care doctor to intervene, and the most they are apt to do is suggest to the patient it’s time to stop driving. 
 

It’s something I feel strongly about, having been involved in litigation over a crash caused by an elder’s reckless driving. I’m not sure an advance directive would work for this. I’ve given my kids a letter to give to me if/when they feel I’m no longer a safe driver. A letter from me, my younger self, to my older self, basically saying don’t be an arse about, just ask the kids to help you obtain transport when you need it. 
 

It’s also a reason that as we look to downsize, we are looking for village concept walkable neighborhoods/city centers. Hopefully lessening the need for vehicular transportation. 

[Terabith]

3 minutes ago, wathe said:

I've had the same thought.   Analog clocks are still plentiful in public spaces here (hospitals, schools, train stations, city hall clock tower etc), but seem to be disappearing in private spaces.  When our kids were toddlers, we realized that we didn't have a single analog clock in the house!  Fixed that with a quick trip to IKEA 🙂 

My kids have certainly SEEN analog clocks, but they have never utilized them as a way to tell time.  My oldest can sorta kinda tell time on an analog clock if given enough time to figure it out.  My youngest cannot at all read them.  I am not sure either one of them could draw one, because they've never been meaningful to them.

[Grace Hopper]

wrt analog clocks

When my kids were little they begged for digital watches. A cheap digital watch was the reward for learning solidly how to read an analog clock. I don’t imagine everyone having such a stubborn hard-nosed mother. (fwiw they can all also swim, perform CPR and drive stick shifts lol, dh and I were tough cookies in that regard).  

[Melissa in Australia]

9 hours ago, Innisfree said:

I think that’s wise. How do people feel about it?

I know my dad  is worried..he is just on 80...

[busymama7]

1 hour ago, Terabith said:

My kids have certainly SEEN analog clocks, but they have never utilized them as a way to tell time.  My oldest can sorta kinda tell time on an analog clock if given enough time to figure it out.  My youngest cannot at all read them.  I am not sure either one of them could draw one, because they've never been meaningful to them.

That's so interesting. We have a large one in our home and use it daily for school schedules, time to leave the house etc.  We don't technically*have* to but I know I am so familiar with one because of the ones hanging in school and me counting down the minutes until dismissal. I just wanted them to be really familiar/used to it. I suppose it may not be super relevant but I hadn't really considered that. I just found a way to fold it into our daily life so it would be. 

[Laura Corin]

4 hours ago, Grace Hopper said:

 

It’s also a reason that as we look to downsize, we are looking for village concept walkable neighborhoods/city centers. Hopefully lessening the need for vehicular transportation. 

In the UK you need to renew your licence every three years from age 70. There's no test unfortunately  - just a declaration of any  illnesses and an affirmation that you are fit to drive.

A doctor can break patient confidentiality in the public interest and contact the licensing authorities if s/he thinks a patient is unfit to drive who is refusing to stop.

The Royal Society for the Prevention of Accidents has a scheme where you can get your driving observed for an hour and receive a confidential report about improvements. It has no weight in law but might help carers.

We have downsized to a village with a shop. It also has direct bus links to the two nearest towns and the two nearest cities. There are regular buses to the nearest train station. The choice of location was strongly influenced by these factors, in addition to being able to stay with a good and thriving GP practice.

[wathe]

3 hours ago, Laura Corin said:

 

A doctor can break patient confidentiality in the public interest and contact the licensing authorities if s/he thinks a patient is unfit to drive who is refusing to stop.

 

Reporting by doctors, nurse practitioners and optometrists for prescribed medical conditions (including cognitive impairment, motor and sensory impairment, sudden collapse, visual impairment, substance use and psychiatric illness), functional impairment and visual impairment is mandatory here and duty to report prevails over confidentiality.  

Doctors, nurse practitioners and optometrists also have discretionary reporting authority for "a person who is at least 16 years old who, in the opinion of the prescribed person, has or appears to have a medical condition, functional impairment or visual impairment that may make it dangerous for the person to operate a motor vehicle", which also prevails over confidentiality.  

The medicolegal consequences are thorny.  Mandatory duty to report means you have to report even if the person voluntarily agrees to stop driving.  Even if the person doesn't have a license etc. In theory, we should be reporting pretty much every nursing home patient who comes through the ED.  And the law does not distinguish temporary impairment from long-term impairment; we should in theory be reporting right lower limb injuries and upper limb injuries like sprained ankles and broken wrists.   We use common sense, but in doing so, absolutely depend on our patient's common sense (which isn't always so common) and open ourselves to liability.

[wathe]

Adding: doctor confidentiality is one way.   MD can't share a patients information with family without consent, but can gather collateral history from anyone.  Concerned family can share their concerns with their family member's doctor, who then has to make a decision about reporting.

[Terabith]

7 hours ago, busymama7 said:

That's so interesting. We have a large one in our home and use it daily for school schedules, time to leave the house etc.  We don't technically*have* to but I know I am so familiar with one because of the ones hanging in school and me counting down the minutes until dismissal. I just wanted them to be really familiar/used to it. I suppose it may not be super relevant but I hadn't really considered that. I just found a way to fold it into our daily life so it would be. 

I certainly spent time trying to get my kids to utilize the analog clocks in their lives.  With my older one, it was moderately effective until they realized there were also digital clocks in the house. My youngest is dyslexic, and we spent a ton of time on clocks before I realized it probably wasn’t going to happen and definitely wasn’t worth the stress.  
 

24 minutes ago, wathe said:

Reporting by doctors, nurse practitioners and optometrists for prescribed medical conditions (including cognitive impairment, motor and sensory impairment, sudden collapse, visual impairment, substance use and psychiatric illness), functional impairment and visual impairment is mandatory here and duty to report prevails over confidentiality.  

Doctors, nurse practitioners and optometrists also have discretionary reporting authority for "a person who is at least 16 years old who, in the opinion of the prescribed person, has or appears to have a medical condition, functional impairment or visual impairment that may make it dangerous for the person to operate a motor vehicle", which also prevails over confidentiality.  

The medicolegal consequences are thorny.  Mandatory duty to report means you have to report even if the person voluntarily agrees to stop driving.  Even if the person doesn't have a license etc. In theory, we should be reporting pretty much every nursing home patient who comes through the ED.  And the law does not distinguish temporary impairment from long-term impairment; we should in theory be reporting right lower limb injuries and upper limb injuries like sprained ankles and broken wrists.   We use common sense, but in doing so, absolutely depend on our patient's common sense (which isn't always so common) and open ourselves to liability.

Interestingly, my doctor did NOT report that I shouldn’t drive when I had my license revoked.  My doctor and my psychiatrist both wrote letters saying that I should not have my license revoked. But because a psychiatric hospitalization was reported by complete coincidence when I was renewing my license because we’d moved, it was revoked automatically.  If I had not been changing my address within the year that I had been hospitalized, nothing would have happened. The hospital didn’t report me. The form asked, “Have you been hospitalized in the last year?” and I said yes. The lesson I and everyone in my family learned was always lie to the DMV. 

[Innisfree]

9 hours ago, Grace Hopper said:

It’s also a reason that as we look to downsize, we are looking for village concept walkable neighborhoods/city centers. Hopefully lessening the need for vehicular transportation. 

 

5 hours ago, Laura Corin said:

We have downsized to a village with a shop. It also has direct bus links to the two nearest towns and the two nearest cities. There are regular buses to the nearest train station. The choice of location was strongly influenced by these factors, in addition to being able to stay with a good and thriving GP practice.

We’re in the process of a similar move. Our new home is in an old residential area a couple of blocks from the main street of a small town. We can walk to a grocery store, two pharmacies, several restaurants, the post office, the library, the YMCA, and several parks and trails.

We love the situation, and were purposeful in finding it. I learned a lot from watching my parents age, including the undesirability of being stuck in a suburban neighborhood without public transportation or a way to get anywhere without a car.

By contrast, my grandparents lived in a neighborhood much like our new one. My grandfather was able to continue daily walks to take care of business well into his nineties. He didn’t have to drive in order to get out, go to the bank, or see friends.

I hope we can continue to have sufficient health to walk around here for years to come. 

[TexasProud]

22 hours ago, City Mouse said:

People can say what they plan to do regarding driving at a certain age or stage, but when dementia sets in, those plans go out the window. My father decided to give up driving all on his own when he was 78 after getting lost in a familiar are one time. Less than 2 years later, the keys and the car had to be hidden from him or he would try to drive. 
I think it is great for people to plan ahead, but I don’t think any document will make a difference in a person with dementia.

 

On 1/21/2024 at 4:49 PM, YaelAldrich said:

I'm laughing because people like that (high powered, smart, driven, used to being in control)  may SAY they will give their freedom up when it's "time", but my in laws and father show me that when the time actually comes, they make every excuse in the book to avoid the loss of control.

 

No the document may not make a difference exactly, but it will make their intention clear when they were thinking clearly.  To be honest, it doesn't have to be written.  My mom told me that when the time came, not matter what she said, I could do what was best: move her to a nursing home, take away keys, etc.  She told me this when she was having to put my grandmother in a facility because she had dementia. They were working and couldn't look after her. She was getting paranoid, leaving the stove on, etc.  Her mom was so upset at her and very almost hateful at the end (She wasn't by nature mean.)  Mom told me that the real her would know that I loved her.  She wanted me to do what was best for me and my family. 

So when the time came and mom had her cancer, I remembered her conversation to me.  I got caregivers when she didn't want them.  For the most part she agreed with me.  There was one or two times where she got paranoid when she was really out of it and told me I was out to get her, but that was rare thankfully.   I had no guilt.

So would the document stand up in court? No.  But it does give the loved one a peace of mind that they are doing what their rational loved one would have wanted.

All bets are off with my husband.  They will take him kicking and screaming. It will be awful. 

[goldberry]

DH and I have talked about writing a letter to our daughter and to ourselves, reminding us how to behave in our old age.  We're dealing with difficult elderly parent issues on both sides right now.  But we also talked about will it make any difference?  No one THINKS they are going to be that old person, and yet..... realistically most of us are. 😔 I hope that even we don't abide by the things we say that it might at least REMIND us, and also give our daughter the surety that she is doing the right thing.  The one thing I want to communicate most to her is that if I really need to be in a nursing home, it is okay to put me there.  Just visit me and make sure I am getting good care.  I felt horrible guilt after putting my mom in the nursing home, even though it was 100% the right thing to do.  I wouldn't wish that on my daughter.