-If you could share one insight on aging, what would it be?

-I'd say aging well is about intention.

When we plan ahead, we advocate for high quality care and we stay socially connected, we get to shape our own experience of aging rather than just reacting to it.

-We're diving deeper into that next, stick around.

♪♪ I'm Cathleen Toomey, host of Seniority Authority, where we get smarter about growing older.

♪♪ Today, we're tackling one of the most important and often most challenging conversations that families face: Talking about aging.

When parents feel like their kids are treating them like children, and adult children feel like their parents are resisting change, frustration builds on both sides.

On today's show, we're so lucky to have Rani Snyder with us, president of the John A. Hartford Foundation who's on a mission to improve the way we care for older adults.

Welcome, Rani.

We have so much to talk about.

We're going to meet one person who was shut down by her dad when trying to have a productive conversation, and she turned it into a social movement.

♪♪ -My mom, I would say my best friend.

Yeah she was my biggest cheerleader, and she was somebody that was beloved by a lot of people.

[woman sighs] It's, it's, it is it is also one of these things that was like nine years ago that she was diagnosed and you think about, oh, when will this ever just like, when is that going to just, soften?

♪♪ She called me up and she's like, you know, I'm not coming out because I'm not doing well.

And a couple, a week later, she's like, I just got diagnosed with stage four ovarian cancer.

And we're like, okay, I'm thinking, what is stage four?

Like, how many stages are there?

And flew out to be with her a week after that and she was just in pain, super uncomfortable and, just trying to be there and be present than try to assess how I can be supportive.

And that was the first time that I, had the opportunity to support somebody that was dying.

And I had zero skills.

How am I in my 50s, and I have no idea what to do to support one of the most important people in my life?

Honestly, I naively walked away from that experience thinking, okay, we got a master class.

We had a, we had a master class on how to die with grace and clarity and, and then when my dad's health started to change I thought, this should be easy you know?

Because we've just all we've, we've all had this experience.

But what, what I did not realize is we all had this experience it was still our own unique experience, and we chose not to talk about it.

And but then I, like I leaned into my dad I'm like a little-- I'm, I'm concerned, and he would not engage with me in any of these conversations.

And I was like, okay, ♪♪ if he dies or goes through the, if he dies when he dies, ♪♪ I don't know how to support him because ♪♪ he was not willing to talk to me about it.

And he would say, I'm pretty sure you and your sister will make all the right decisions when the time comes and I'm like, well, I don't know about that because we're pretty, very opposite on, on a lot of big life things.

And I said, I feel that if you use that strategy, you're going to be you're going to be dying and dead, and we're going to have some really difficult times afterwards and that doesn't seem like that's fair, you know?

So help us help you.

It got me really curious where where do people go to talk about death and dying, outside of a doctor's office or a religious institution?

I started, you know, googling.

I was like where what oh okay, there's, there's there's opportunities to talk when you have a terminal diagnosis or a life-limiting illness.

But where do where do I go right now?

Just to try to like, I, I kind of want to catch up that, and, I have, I have a daughter who's in her 30s its like, how do, how do we talk about these things?

She was not interested to talk to me.

And I was like, okay, so that's when I just started doing this deep dive and started just reading, listening, watching things about death and dying ♪♪ just to try to make sense of it.

I, I do I, I believed that there were more people than just me that were looking for something more upstream, and it was from there at or all at that same time, I'm like, I think I have to do something different.

That's when I said, I think I wanted to start a club.

♪♪ I, I think said nobody, I want to start a club to talk about death.

And I joke with my dad and I just say, you know, dad, I started a social club to talk about death because of you.

And he's like, you're welcome.

[Laura chuckles] And, and it's true.

It is so true.

And I tell him, I go, let me let me expand on that.

If it was so easy to talk to you about, death and dying like it was mom.

♪♪ I wouldn't be this I would be still oblivious so this is easier for everybody.

So it's like, dad, you've given me a gift that you had no idea was, so important because it's opened up so many other things in my life.

♪♪ [music fades] -Well Rani, I know this situation isn't new to you.

Your focus has covered so many aspects of aging.

In your experience, how do we make these tough conversations like laura’s easier and more productive?

-So at our foundation at the John A. Hartford Foundation, we emphasize the importance of goal oriented conversations.

So really understanding what truly matters to older adults and working towards solutions together rather than making assumptions about what's based-- what's best for them.

And that's especially true when it comes to health care.

It's-- this is really at the heart of what we call age-friendly care, and age friendly health systems, which is a movement that we championed to ensure that older people receive health care that's aligned with goals and values and not just any of our medical conditions alone.

But another reason it's so challenging to have conversations about aging is because it's kinda taboo in our society.

Ageism, which is really discrimination based on age, is all over the place.

We, we have ageist beliefs about ourselves even, and it gets in the way of how people and families are having the kinds of conversations that we want to have, about getting older.

Conversations about aging are often shaped also by cultural expectations, by other things that we don't talk about, like financial realities and sometimes family history, which is why they have to be approached with with respect, and patience, and that focus on what matters to the older adult.

-And we know that family dynamics are certainly not new, as you pointed out.

But why is it that so many people find this conversation in particular challenging?

-Well, that's because, we, they allow older adults to have agency over their own future.

And that's, it's really important to have those conversations.

So, here's a good moment where I can talk about age-friendly care and what we call the four Ms.

And the four Ms are what every older adult should be thinking and talking about with their family, with their health care providers, because they're really the most important factors in, in getting good outcomes.

What matters?

First and foremost, understanding and honoring an older person's personal goals and preferences.

And the other three are medications.

I mean, that's something that I think makes sense to all of us, ensuring that medications are age appropriate because, some medications affect older people differently and that those medications don't cause harm, and of course, that they also correspond to what matters most, to, an older person in their family.

Mind, so that's a, a third M which is addressing cognitive health, preventing and managing, conditions like dementia and depression.

And then last but not least, mobility.

So helping older adults stay active and independent and avoid falls and that's really, about physical function.

So those four Ms are a set and they are all interrelated so if you think about it, if you're on the wrong medications, it can affect your mind.

It can affect your mobility if your balance is off, let's say potentially putting you at risk for fall.

And that in turn gets in the way of what matters to you.

So by talking about, it's an easy to understand set and by talking about those four Ms with family members, what matters to me in my life and in my health, how is my memory?

Am I worried about forgetting more?

How are my medications affecting me?

How active and mobile am I?

And then talking to healthcare providers about those four things can really help you achieve better health.

-I like that.

How does our increased longevity put more pressure on having this conversation?

-We're living longer than ever before.

And, that longevity is a gift, that brings new opportunities and new challenges.

Many of us will spend decades in older adulthood, and that requires long-term planning.

And that's, not just for health care, but also for social connections, for financial security, for maintaining our independence.

And so, when we discuss as families, when we discuss aging, we should think holistically.

Not just about health care or not just about any one of those pieces, but about overall quality of life.

So we need to think about long term needs.

-In your experience, what are the most typical reasons that having these conversations with-- between parents and older adults, why does it typically breakdown?

-People are busy.

Maybe they're nervous.

We're definitely inexperienced with these kinds of conversations.

They don't come around very often so, if any of us if I as an adult child, come in with a here's what we need to do mindset, it often will feel like, it, it’ll feel sudden and abrupt and it can feel like a loss of autonomy I would say for an older person.

So, ideally, instead, these conversations should be collaborative.

They should start with questions like, what's important to you as an age?

As you age.

what do you want your future to look like?

Another reason they sometimes break down is timing.

So, as I referenced, often times families wait until there's a health crisis, at which point stress levels are high.

There's often time pressure, which prevents us from sort of the ideal information gathering we might like to do, and at that point, options can be limited too so the earlier we're able to begin those conversations so that, older adults can actively shape their own future, the better.

I mentioned before, also cultural expectations, which can play a role.

So in some cultures, adult children are just expected to be caregivers, while in others independence is really highly valued.

You can see that mix within an individual family even.

So these kinds of differences can also lead to conflict, particularly when they aren't openly understood or acknowledged or discussed and that's really common.

And I guess the last thing I'll say is, conversation can break down without, that preparation and some guidance.

And I do want to note that there are some existing tools that can be helpful.

So I'll list a couple of those.

One is called My Health Checklist.

It's from the Institute for Health Care Improvement, and it's a practical, really easy to use guide that walks people through those four Ms that I referenced, so that you can walk into a health care appointment, prepared.

Another is a program called Patient Priorities Care, and that's especially helpful for aging adults who have a lot of complex conditions.

And it helps them to identify the what matters piece by helping them to be really clear about health priorities.

There's also an initiative called The Conversation Project, which has terrific guides to help you have conversations about that advance care planning that I mentioned and what you, what you want, should you face a serious illness.

And then the last thing that I will reference is an important part of advance care planning is having your medical directives documented and easily accessible to share with family, or health care providers and there's been a kind of a historic disconnect so all of the things I referenced already are health systems focused.

But a lot of people think about these kinds of documents in conjunction with their legal planning.

You know, like when you're thinking about wills, and living wills.

We worked with, the American Bar Association several years ago to create some guidance for lawyers on these really important health related topics to build connections between lawyers and clinicians who need them in the moment so that there can be practical tools for this kind of sort of medical legal cross-referencing.

And they created an app that's called Mind Your Loved Ones so that you can download and, to use and store securely, securely share rather your critical medical information and directives if you become too sick, to talk for yourself.

So you can find any of that information on our website but the point really is that folks need to know that these resources are out there.

-I think that's important, and they are all free resources available at the John A. Hartford Foundation dot org.

So in your opinion, is this kind of a one and done conversation?

-Not at all.

You've heard this expression before and I'm going to apply it to this situation: Aging is a marathon, not a sprint.

And that goes for this conversation as well.

The best approach really is to start early and revisit dialogue often.

Recognizing that for all of us as our health, our finances, and just our personal preferences evolve, things change.

-In theory we all know it's healthy to have these conversations, but in practice, how many of us actually do it?

Well, there's one group called the Pre Dead Social Club and they are talking about it every month.

Let's take a look.

♪♪ ♪♪ [water running] -Welcome!

inside are, nametags and things grab something to drink, find a spot.

Alright, we'll be in there shortly.

[faintly] -Thank you.

-This is your first time?

-Yes.

-Yeah?

cool.

-I'm Laura, nice to meet you.

-Hi Laura.

♪♪ -Welcome to death over drinks.

Where drinking is not required, but we hope you lean into conversations about death, dying, and end of life.

♪♪ -I started coming to death over drinks, over a year ago.

I enjoy the people.

I enjoy the community and the purpose of why we get together, and to find like minded people who want to talk about it versus, you know, not talk about it.

-I've been interested in death and dying for a while.

I believe that we need to have more spaces to talk about death.

-Age-wise, there are people dying all around me, so I want to get a little wisdom.

♪♪ -I think it's hard to talk about.

I think it's hardest to talk about with people who you're very close with.

We talked about that tonight the fact that, like, sometimes it’s the in-laws or the cousins or like those slightly more removed people and so coming and talking with total strangers just, strangely, is much more comfortable and easy to do.

And it sort of gives you practice so that you can go back and have the conversations, with the people that it's harder to have them with.

♪♪ -Yeah I think people, people are like, okay, interesting.

And then usually the first question is like, is it a grief club?

And, no it's not really it's more of a curiosity club.

It's more of a curiosity about like humanness, you know?

About living and dying and, and, you know, I'm, I'm a younger ♪♪ one of the group, and I feel really just grateful to be around so many people with, decades of life experience.

Like, that's kind of why I come back it's just, ♪♪ they're telling about what happened to them when they were my age or, you know, what they're going through now.

It's cool.

It's cool in that way to connect in intergenerational ways.

-As a person who lives by myself, I need social.

So I never know who I'm going to meet, or what I'm going to, to learn here.

♪♪ -Based on my personal experience it really helps to talk about it before you need to, and to think about it before you need to, because everyone's going to experience it.

It's just a matter of when not if.

♪♪ -All gonna have to do this, it’s not about what I-- -The more I know and understand about death and dying, I feel more centered and grounded in living today.

-There's an app out there which I have never looked into, that apparently randomly reminds you throughout the day that you're going to die and, and supposedly the research behind it is that people who get those reminders live happier and fuller lives so I think, yeah, not taking days for granted, knowing that, you know, it will end for all of us at some point I think does make you notice the things that you might have otherwise taken for granted.

♪♪ -We feel all spectrums of human emotion I think when people usually associate death, they think about grief, sadness.

But, there's so many other things that come along with that happiness, laughter, regret, you know, shame, so many other parts of being human that are wrapped in that death bow and we get to kind of unpack it in a really light hearted way sometimes, but really also heavy topics, which is cool.

-And I mean, I don't think it's just death, right?

I think we shy away from a lot of hard conversations.

We have a hard time telling our friends they have spinach in their teeth or that their fly is down right?

So when it's like, let's talk about death, that's a very big leap.

-I wish people knew that it's not going to kill you to talk about death.

♪♪ [chuckling] Yeah, you're not going to bring it on, by talking about it, you're only going to reduce your anxiety.

-The last thing I wrote was something Shelby just said: Dying is a process, but death is an event.

-Mhm.

♪♪ Super cool, thank you so much.

[applause] Yeah.

[applause fades] So Rani, there are people that are talking about this, but for those who are not participating in death over drinks, can you share the keys to having a productive conversation with-- between generations?

What are the do's and don'ts?

-So I'll give you some potential do's and then some don'ts.

I would say do start early.

Do not wait for a crisis.

The sooner these kinds of conversations begin, the more choices will remain open.

I would also say do ask, don't assume, there are some families where they don't want to talk about it like we saw in that first clip.

And, but if you begin with sort of open ended questions about, you know, what's important to you, you're more likely to get traction.

I would say then do listen actively, acknowledge sort of feelings and validate concerns rather than rushing to solutions.

That's another thing that a lot of us will do that sort of gets in the way.

You can use the four Ms framework, so discussing what matters, medications, mentation and mobility as a way to structure the conversation and some examples would be asking of course what matters most and what are a person's goals for aging well?

Reviewing medications to make sure that they support long-term health, monitoring our cognition, you know, is there a plan for cognitive health?

And then just considering mobility, everybody has different preferences about the ways they want to stay active and independent.

And it's a good idea to revisit those regularly as I mentioned, aging is a path we are all on at least that's the best situation.

And our needs and preferences change over time.

Here are some don'ts.

Don't be directive or controlling.

It sounds obvious, but it's much harder to do when you're speaking in a in a family situation.

Try to avoid phrases like you need to or you should.

I-- instead center that conversation around choices and preferences.

We already said this, but it bears repeating don't wait until there's an emergency.

High stress situations make decision making harder, and for a lot of us, a lot more emotional as well.

Here's another one that we see in many, different facets of our life and it applies here, don't overwhelm with details.

These conversations ideally should unfold over time, and it really helps if we can focus on values first and logistics later.

Another, more subtle piece is to, to, you know don't ignore emotional cues.

If someone starts shutting down or getting defensive and I feel like many of us will experience this, that means it's time to step back and revisit it when they're ready.

It's, it's fine to do that.

It's easier to do that when you're not in that urgent situation.

And the last thing I'll say on that is, you know, by framing this conversation collaboratively and with care, all of our families are gonna to have a better chance to ensure that, our older adults feel heard and respected and empowered and want to have these conversations as well.

-That's so important.

It's so important, especially the emotional cues, because I think many of us come at this like a check, we have to get this done and sometimes that is just not the right time.

I, I cannot tell you how grateful I am that you've got the John A. Hartford Foundation that is solely focusing on older adults.

It is such a gift.

The work that you're doing and your team is doing to try to make lives better for older adults is, is so important.

-If I may, I'll say one last thing.

-Yeah!

-I have to note, because it's a big part of this conversation that as part of age-friendly care people should know, that support for family caregivers has got to be built into this.

Our foundation has a number of programs and, and policy change initiatives to make sure that the wives and the sons and the daughters and the husbands and, and friends and partners of older people have the support that they all need as well.

-You are absolutely right.

53 million, Americans who are providing unpaid family care, and most of them are not trained and did not anticipate doing this so it's, it's a lot so thank you for, for doing that because that's really critical.

Rani it's been such a gift to have you on the show today, thank you so much for joining us and sharing with so many people the tools and the recommendations, all of which are free and available and hopefully are going to change a lot of lives.

♪♪ -We'll, we'll do our best.

♪♪ -To learn more about the John A. Hartford Foundation, and to keep the conversation going, visit NHPBS dot org slash Seniority Authority.

♪♪ Until next time, stay curious and keep thriving.

♪♪ -Major funding for the production of Seniority Authority is provided by Road Scholar.

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