Independence and Aging: Redefining Freedom for Older Adults

Moving Beyond "What's the Matter" to "What Matters to You"

Mrs. Alvarez, 90, arrived at our emergency department gasping for breath. Her chart read chronic heart failure, stage III COPD, and mild cognitive impairment. The on-call intern focused on "what's the matter"—shortness of breath, swollen ankles, fatigue. Lab work, diuretics, and oxygen therapy stabilized her vital signs, but Mrs. Alvarez lay quietly, eyes fixed on the ceiling, unresponsive during rounds. The nursing staff whispered she was being "difficult"—barely eating, refusing therapy. "If you don't eat, you won't get better," they'd say.

That evening, social worker John pulled up a chair and asked a different question: "Mrs. Alvarez, aside from the breathlessness, what truly matters to you right now?" She blinked back tears. "I haven't held my great-granddaughter's hand in months. I miss the smell of marigolds in my garden and Sunday Mass at my parish." This simple shift changed everything from "what's the matter" to "what matters".

As we celebrated Independence Day this July, I reflected on a different kind of freedom: the right of older adults to age on their terms, with dignity and meaningful life choices.

After thirty years as a geriatrician, I've seen how well-meaning families and healthcare systems can inadvertently strip away the very independence they're trying to protect. Today, I want to share what true independence in aging means.

The Reality: When 911 Becomes a One-Way Street

Here's the reality: When people aged 80 and older call 911, at least half end up in the emergency room. Thirty percent of those aged 80-89 get admitted to the hospital, and 40-50% of hospitalized patients aged 85 and older don't go directly home—they're discharged to nursing facilities.

For many frail older adults, calling 911 can become a one-way street away from independence.

This cascade isn't inevitable—it results from systems designed around efficiency rather than patient autonomy.

WITH, FOR, or TO: A Critical Framework

I often ask my colleagues: Are we doing this WITH the patient, FOR the patient, or TO the patient?

WITH the patient represents true partnership, honoring their expertise about their life and priorities.

FOR the patient means good intentions, but it may not align with what the patient actually wants.

TO the patient strips away dignity, turning patients into passive recipients of care they never chose.

This distinction is crucial for frail older adults who often find themselves on that devastating pathway from 911 call to nursing facility, frequently without meaningful input into these life-changing decisions.

When "What Matters" Transforms Care

The shift from "what's the matter" to "what matters" isn't just semantics; it can literally transform outcomes. In Mrs. Alvarez's case, the team worked together to honor her values:

• They arranged chaplain visits and streamed her parish's Sunday Mass

• Coordinated FaceTime calls with her great-granddaughter each afternoon

• Placed potted marigolds by her window

• Scheduled short walks in the courtyard garden

The staff added these goals to her whiteboard alongside medical orders, giving her priorities equal status with vital-sign targets.

Within days, Mrs. Alvarez's eyes sparkled again. She smiled watering her marigolds with volunteers. She laughed when her great-granddaughter waved on the tablet. Her appetite returned, and she willingly completed physical therapy so she could stand by the garden wall.

But here's the crucial point: asking "what matters" isn't always the simple way out. It's often more complex, requiring creativity, coordination, and sometimes difficult conversations about what's realistic.

The Complexity of Real Solutions

Let me share another story that illustrates both the challenges and possibilities. Margaret, 84, had experienced three falls in two months. Her daughter Sarah was pushing for assisted living. "Dr. Wong," Sarah said, "we just want her to be safe." When I asked Margaret what mattered most, she answered immediately: "I want to keep making my famous Sunday dinners for my grandchildren."

This wasn't a simple request. Margaret's balance was declining; she had arthritis that made chopping difficult, and standing for long periods was becoming dangerous. The easy answer would have been "that's not safe anymore." But we worked together to find solutions:

• A home health aide came twice weekly to help with meal prep and safety

• Family members rotated Sunday assistance, turning dinner prep into a multi-generational activity

• We arranged for adult day care three days a week, which included a cooking group that kept her skills sharp

• Physical therapy focused on kitchen safety and balance

Six months later, Margaret still hosted Sunday dinners, but the path there required significant support, coordination, and honest conversations about accepting help.

Sometimes, honoring "what matters" means recognizing when the original plan isn't feasible. Another patient, similar to Margaret, ultimately chose to move to a senior living community, not because we gave up on her independence, but because they had an active baking group where she could continue what mattered to her in a different setting.

True independence isn't about maintaining everything precisely as it was; it's about preserving what gives life meaning while adapting to changing realities.

Why "What Matters" Works

This isn't just feel-good medicine. When healthcare providers ask "what matters to you?" and act on the answers, we see faster functional improvement, better treatment adherence, reduced anxiety, and shorter hospital stays.

When Mrs. Alvarez seemed like a "difficult patient" who wouldn't eat or participate in therapy, the real issue wasn't medical non-compliance—no one had bothered to understand what gave her life meaning. Once the team honored her values, her entire trajectory changed.

This approach recognizes that patients are experts on their own lives and values. Healthcare should serve these priorities, not override them. It's not always the simple path, but it's the better path.

The GOLD Approach to Independence

When supporting independence for older adults, I recommend the GOLD approach:

• Gradual changes, starting with what matters most. Don't wait for a crisis to discuss goals and preferences.

• Open dialogue about needs and values. Create spaces where older adults feel heard and respected.

• Loving support that enhances rather than replaces autonomy. Independence doesn't mean isolation.

• Dignified care that honors the person's life story and right to shape their aging journey.

Building Better Systems

We need emergency alternatives that preserve independence:

• Telemedicine consultation services

• Mobile healthcare units with geriatric specialists

• Family emergency plans developed before crises

• "Hospital at home" programs

• Systems that ask "what matters most?" and honor those priorities

Margaret's Journey Continues

Margaret's path wasn't straightforward. It required frank discussions about safety versus independence, coordination between multiple services, and ongoing adjustments as her needs changed.

The home health aide didn't just provide safety—she learned Margaret's recipes and became part of the family tradition. Adult day care helped Margaret maintain her skills and confidence. Family members discovered that helping didn't mean taking over.

When Margaret had another fall, we didn't default to "this isn't working." We asked again: "What matters most now?" Her answer had evolved, and she was open to different solutions.

Today, Margaret lives in a senior community where she leads Sunday dinner preparations and teaches other residents her family recipes. She didn't keep everything exactly as it was, but she preserved what mattered most—bringing people together through food.

The Freedom We All Deserve

Every older adult deserves:

• The right to make decisions aligned with their values

• The liberty to choose quality of life over quantity when that matters most

• The autonomy to remain home with support rather than institutional convenience

• The fundamental right to be heard and respected as the expert on their own life

Real independence means having access to honest information, meaningful choices, and support systems that enhance rather than replace autonomy. It means being asked "what matters most to you?" and respecting that answer.

Healthcare that truly honors independence recognizes that the patient is always a person first, with a complete life story and the fundamental right to shape their aging journey.

The goal isn't to age without support—it's to age with choices.

Warmest Aloha,

Dr. Warren Wong

PS: I say it over and over again: There's no one more important than the caregiver in the daily life of a frail person.