An occupational will can be a helpful tool
Mental decline a reality for those who continue to work in senior years
My wife says I love my work too much to ever retire. Perhaps she’s right. But my experiences as a neurologist and clinical director of an Alzheimer’s centre have led me to think a lot about the circumstances under which it would be wise to move on. In fact, having reached my 60s — joining the fastest-growing segment of our population — I’ve been considering what changes in my cognitive capacity would lead me to no longer wish to keep on working.
More specifically, I’ve begun to develop an “occupational living will,” something akin to a medical advanced directive but expressly intended for one’s professional life. Some recent encounters with patients at our centre have convinced me of its value and potential urgency.
When I was a young physician, I noticed there were always a few older, formerly very accomplished doctors who would consistently stand up during important meetings and make irrelevant comments that caused me and others to cringe. If I helped to take care of their patients, I was often struck by the mediocre treatment they were providing. We youthful colleagues remained oblivious to the possibility that their fate could ever become ours.
Since then, I’ve helped care for many previously high-functioning professionals with progressive dementia illnesses. Depending on the stage of the disease and the degree of disruption of brain systems important for self-awareness, patients have widely varied insight into their predicament and appreciation of the impact of their neu- rological disease on their work.
This lack of self-awareness was disturbingly evident in the case of a professor in her mid-60s who continued to give lectures, supervise students and even consult, despite being diagnosed with Alzheimer’s disease of mild to moderate severity.
When strong cognitive-testing evidence of her deteriorating mental status and examples of her difficulty carrying out professional responsibilities were brought to her attention, she insisted her problems were minor. Sadly, these “minor problems” included delivering the same prepared lecture to her class twice in one week and the recurring loss of bowel control, even during interactions with students.
For many of us, including this professor, work is not simply a job but a calling. We may experience giving up work as losing our selves, or at least a big chunk of who we are. Members of my own profession are well known for their commitment to their work, so it’s not surprising that almost 30 per cent of active U.S. physicians are over 60
Working into old age has many potential benefits. The intellectual and social stimulation derived from continuing to work as we grow old is very likely to promote brain health and counteract cognitive decline.
The accumulated knowledge and experience of seasoned workers benefit companies and organizations, and may help offset future personnel shortages.
Many of my older colleagues continue to be amazing sources of clinical wisdom and expertise.
Nonetheless, by the time we reach our 60s, most of us have developed some concerns about losing our cognitive faculties. An estimated 15 to 20 per cent of adults ages 65 and older suffer from mild cognitive impairment, and10 per cent suffer from dementia.
Despite fears about possible mental declines, few of us have generated concrete strategies for addressing them. Like other unpleasant possibilities, we tend to avoid thinking about them.
Moreover, most Americans have not designated a healthcare proxy to speak on their behalf if illness silences their ability to do so for themselves. Few have had discussions with loved ones exploring under what circumstances they would want modern medical science to step back from prolonging the dying process.
I suggest that an occupational living will is particularly important for adults approaching their 60s or beyond, especially those with no intention of retiring. This exercise would provide an opportunity to seriously consider our individual threshold of cognitive or functional decline that, if crossed, would signal the need to stop working. One extreme position would be to choose to retire when we could no longer perform at a level equal to our highest degree of competence and creativity. The other extreme would be to plan to work until the day we die, regardless of our intellectual capacity, performance or ability to contribute.
Between these extremes is the exemplary course of action demonstrated by another one of my patients, also a professor in her mid-60s. She was evaluated for mild but disruptive cognitive difficulties (slow recall of information), and a neurological workup revealed underlying Alzheimer’s disease.
She shared her diagnosis with close colleagues in her department and continues to teach, but with the support of other faculty members.
Co-teaching classes, a lighter workload and written notes have provided a meaningful scaffolding for her to continue to offer her expertise to her students.
With the backing of our clinical team, she asked colleagues to monitor her performance and will use their feedback to guide future decisions about work.
Her example has led to an evolution of my thinking. I am no longer focused solely on determining a threshold for my eventual retirement.
I also seek to lay the groundwork for handling a period of gradual mental decline and deterioration in my ability.
This will probably entail the development of a transitional plan consisting of accommodations, increased support and diminished responsibilities, similar to those adopted by my proactive patient.