We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Perspectives | Less Is More

My Mother the Gardener FREE

Irene M. Wielawski
Arch Intern Med. 2012;172(15):1131. doi:10.1001/archinternmed.2012.2378.
Text Size: A A A
Published online

My mother died at age 90 years from complications of a fall at home. The “at home” part was the triumph of her last decade. Having spent 3 years in a German slave camp during World War II, she was terrified of institutional settings. Assisted-living facilities and nursing homes were tantamount to prisons, in my mother's view, and woe to anyone who suggested otherwise.

As a HIPAA (Health Insurance Portability and Accountability Act) designee, power of attorney holder, and lifelong confidant, I had been drilled from an early age to go to the mat with anyone who threatened her freedom to live as she wanted. This is your job, she commanded—over and over again until I wanted to cover my ears. Yet I understood the fear that underlay these 2-fisted pronouncements and promised to do my best.

And so I did.

When hearing and cognitive losses set in during her 80s, I began accompanying my mother to physicians' appointments. At first I sat quietly—my mother wanted me there, but she also wanted to run the show. Over time though, she became more tentative and anxious about medical procedures that she had once handled stoically. This led me to question the need for routinely prescribed screening procedures like Papanicolaou tests and mammograms. My mother did not sleep for days beforehand—were they really necessary?

Some of my mother's physicians engaged with these concerns, others coldly recited medical quality standards. Privately, I worried about challenging medical norms—what if something bad happened as a result? I wanted to do right by my mother but how to achieve that was not always clear in the moment of decision.

Ironically, the person with whom I memorably “went to the mat” was one of my mother's most conscientious physicians. He was a scholarly and gentle young physician in our small-town hospital. Like me, he also wanted to do right by my mother. But when it came time to discharge her after a 4-day hospitalization for atrial fibrillation and heart failure, he got so engrossed in triangulating data points from her voluminous electronic health record that he lost sight of the person he was treating.

The problem was the warfarin prescription he wanted to send her home with, along with stomach injections of enoxaparin until the warfarin therapy became effective. In the hallway outside her room, he excitedly told me that he had figured out a dosing and injection regimen that when added to my mother's other heart drugs would reduce her stroke risk almost to that of “you or me.”

I listened in horror, picturing my mother's life at home. She was an avid outdoors woman and gardener—and not of the flower bed variety. She had planted every bush and tree on the hilly property where she and my father built their American dream home and took pride in maintaining it after his death. She was outside every clement day, armed with hedge clippers or worse. Famous for her dogwoods that exploded in glorious flower every spring, my mother proudly shared the secret of her success: rigorous pruning, which she did herself with an 8-foot pole cutter.

Over time, my drop-in visits took on a first-aid aspect as I patched up scratches—and sometimes bloody gouges—from these horticultural adventures. Though my mother sweetly accepted administrations of hydrogen peroxide and admonitions to “Wear your gloves!” it was clear that nothing was going to keep her indoors or sedentary on a nice day. Working her land was my mother's definition of living.

The physician knew this about my mother, and also that she lived alone. I had taken pains to brief him on her lifestyle because it ran so counter to the stereotype of women of her age and infirmity.

But his singular focus was on thinning blood sufficiently to counteract her sluggish heart's penchant for throwing clots that could cause a stroke.

But is not warfarin-thinned blood dangerous in someone with my mother's activities? I asked. He replied with percentages and relative risk equations. I countered with hedge clippers, pole cutters, and unsteady legs due to arthritic knees. He suggested I sit down with my mother to discuss lifestyle changes that would accommodate her prescriptions.

And so we went, back and forth until I asked him if there was an alternative to warfarin that might be safer for her—and also more likely to win her compliance. Baby aspirin, he replied, looking crestfallen. He pointed out that the research literature showed some benefit but less reduction in stroke risk compared with warfarin.

With a bit of coaching and a pill chart that we made together, my mother successfully added aspirin to her daily medication regimen and enjoyed 2 more years of relative independence in her home and garden. Her death, from complications of a fall while she was doing her laundry, came mercifully swift.

In retrospect, I am glad I was able to help my mother wrest the kind of treatment she wanted from the health care system, even if it fell short of science's gold standard. But I wish I had had more help with these decisions. They are hard calls for clinicians, I realize, but they are even harder when you are on your own, trying to do right by a loved one.


Correspondence: Ms Wielawski (imw@cloud9.net).

Published Online: July 2, 2012. doi:10.1001/archinternmed.2012.2378

Financial Disclosure: None reported.

Funding for Less Is More: Staff support for topics research funded by grants from the California Health Care Foundation and the Parsemus Foundation.





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles

Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed
How Can I Apply the Results to Patient Care?

Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed
Does the Study Help Me Understand Social Phenomena in My Practice?