“The hardest part is every time the phone rings or if there’s a text message. What’s next? What’s going on? If you’re there and you’re seeing her, it’s easier to, you know, react.”

 

Sunlight filters through the windows, shining on various potted plants in the house. Out back, the dogs Frankie and Quincy lay out on the warm cement. In the front yard, my grandmother slowly tends to her plants, being careful not to bend down too much. She is ninety-two years old, and it has been three years since I’ve seen her. She survives her late husband and youngest son, whose deaths have been hard on her over the past seventeen years. However, she is still in the company of her eldest son Sonny and her grandson Jean. Oceans away, her only daughter, my mom, watches over her.

 

When I sat down and started talking to my mother about Grandma, she first laid out her medical condition, typical of a doctor: diagnosed with renal failure at age ninety-one, recommended dialysis twice a week, had a history of angina (chest pain) and stomach ulcers, had three stents put into her coronary artery, had hypertension, and a recently developed back pain due to spine compression. She was quick to remark one other thing: her memory. “Her mind is still very sharp, like fifty year-old person. It’s amazing for a person of ninety-two,” she said with admiration. My mother has always hoped that she inherited the family mind and longevity genes.

 

At this point in her life, Grandma is ready to go to heaven and be with Grandpa and Uncle Ed, though she has been grateful for the “ten years bonus” that God has given her. Because of it, she has had the chance to watch my brother, my cousin, and I grow up. Grandma, Uncle, and Mom agreed that when the time came when she would be in critical condition, they would not try to resuscitate her or give her any aggressive treatments. “Her outlook, actually—she is very practical,” my mother concluded with a great acceptance. It was a relatively easy decision for them to agree on.

 

Part of the ease came from how Grandma had experienced end-of-life care before. She had taken care of my grandpa during the last years of his life, and she didn't want to be bedridden like he had. She knew that this would be hard both for her and her caregivers—her children. “Everyday she pray[s] to God that, when He is willing to get her anytime, just get her quick.” That is all she asked for. When I asked my mom if there was any advice she would give to others in a similar situation, she emphasized the importance of having that conversation about the end of life. “How long would they like to live? How long would you not give up on them?” My mom was the first person I spoke to for this project. Conversations about the end soon became a theme in the stories of the others whom I spoke to. Talking about the end of life can be a very difficult conversation to have, but it makes planning for the future and deciding on care during the present easier.

 

***

 

One of the aspects of her situation that my mom made most clear was how her medical degree compensated for her distance. My mom finds it easy to remedy any of my grandma’s physical pain. Being a doctor makes her valuable source of support and information during critical times. For example, one early morning, Grandma called to Uncle Sonny, expressing shortness of breath and chest pain. Uncle’s first thought was to take a cab and bring Grandma to the hospital, but he decided to call my mother first. She calmed and reminded him of Grandma's history of chest pain and told him to administer a certain amount of medication. This saved them a trip to the emergency room.

 

Being a doctor also helped her communicate with Grandma's attending doctors, asking questions and making sure that they update her on anything about her mother’s health. For example, a doctor who had not taken Grandma’s history gave her pain medication that aggravated her stomach ulcers. My mom reported the history to the doctor, who promptly switched up the medication. “Yeah, I think the overall conclusion would be...I will not be able to know if she is getting the best care or the right medical care needed. But I will not dismiss the idea because, of course, they will be able to do the right thing. But I think, in terms of checks and balances, I think its better that we are able to be in the same field.” Having the knowledge helped her trust the people taking care of her mother.

 

At the same time, having this knowledge creates a tension between the roles of daughter and doctor. “Its harder to treat you know your loved ones and family members as regular patients because you get some emotional, and you want to do everything you could to alleviate their pain. And so it’s very hard very hard you want them to still be with you for a longer period of time but you don't want them to see them suffer.” Especially now, with the recently developed back pain, there are days when Grandma cries to my mom, telling her that she is ready to go. It hurts to hear that from a person in general, but it hurts more when it is someone you love. Even though my mom prides herself on her medical knowledge, she understands that it’s not enough to take away all pain.

 

So what does this mean for people who also are caring for a loved one from afar? My mom told me that you don't have to be a medical professional or have to have a medical person in your family to make sure that your loved one is taken care of well. One of the best ways you can handle care is making sure to be updated on their medical condition. If your loved one goes to the doctor, make sure that they either take notes for you or get to have you speak with the doctor directly, such as by phone. If possible, it helps to have someone else, maybe another family member or a friend, go to appointments with the loved one. For example, Ms. Tricia, who is not a medical professional, had parents who wanted her to come into the consultation room with them because they were worried that they wouldn't remember to ask all of the questions they wanted to have answered. This is also what my Uncle Sonny does. Anything that he hears from the doctor, he relays to my mother.

 

And, if you’re unsure about a suggestion about treatment, you can go to other medical professionals for second opinions. In fact, this is something that my dad, who is a pulmonologist, encourages for patients. Whether or not the second opinion agrees with the first doesn't matter. Having more information can help families decide how to proceed with care and can help caregivers from afar contribute to healthcare decisions even if they are not there. Maintaining communication regarding your loved one’s medical condition is something that can be harder to do remotely, but it can still be doable.

 

***

 

My mother emphasized the importance of at least having one person present with the loved one. In her case, her saving grace is Uncle Sonny, who is the main caregiver of my grandmother. At the moment, he is not working. He feeds her, helps her with cooking, makes sure that she takes her medications, and brings her to dialysis, just to name a few of actions he takes.

 

Over the past few years, he has suffered from three strokes. There was a point when my grandmother became really worried that Uncle would pass away before her. “I tell her that that's not going to happen. Your Sonny is still not old. He will be fine and that's the last thing you will have to think about.” Everyone in the family has taken actions to help him quit smoking. With being the sole caregiver and also balancing other responsibilities, he has been overwhelmed, It makes sense how he has resorted to smoking as a coping mechanism. From afar, my mother can provide medical advice and psychological care, but Uncle takes care of the rest. My mother confessed that, if my Uncle Edmund were still alive, things would surely be easier. Perhaps Uncle Sonny would be able to work and he would not be under so much stress. Nevertheless, she is very grateful for Uncle. He does his best to take care of her even though his own health is compromised. Family members check in with him to make sure that he is doing okay, and some come to visit in person, which helps both my uncle and my grandmother.

 

Carrying these responsibilities, even if you are not a primary caregiver, can be overwhelming. It’s important to understand that there is only so much that you can do as one person and that you need also support, just as your loved one does. In my conversation with Ms. Tricia, she stressed how important self-care is and offered several suggestions on how to cope when feeling overwhelmed.

 

***

 

Being far away can still be difficult. While having the medical knowledge helps her monitor my grandma’s health and well-being, during the past few months, it has been hard for her to relax. She explained to me, “The hardest part is every time the phone rings or if there’s a text message. What’s next? What’s going on? If you’re there and you’re seeing her, it's easier to, you know, react. But it’s feasible. It’s just that I’m up on my toes all the time. How severe is it? Should I be flying home to the Philippines and check out?” At the moment she is unsure when will be the best time to come home. If my grandmother lasts to the New Year, she might go see her there.

 

In the meantime, one of the ways in which she cares for my grandmother is making note of the things in life that she still enjoys. For example, she makes sure that there is family to visit her. “She loves having relatives and friends visit. It makes her happy and very alive.” Except for dialysis treatments and occasional trips to the grocery store, my grandmother can’t leave the house very much. So these it means a lot for her to see people she wouldn't otherwise see. Fortunately, my mom’s side of the family is very large, and even distant members remain close. Food is another good example. At the age of ninety-two, my grandmother’s sense of taste has diminished significantly. Because of this, my mom makes it clear to her that she can eat anything she wants. With her immune system so weak also, at this point, she can eat anything she wants for the sustenance. “So I told her 'Enjoy! If you want to eat all the fat you want, you can,'” she told me, laughing.

 

Overall, my mother wants to respect any of the wishes that my grandma has. She wants Grandma to be able to enjoy the last years of her life to the fullest, and hearing Grandma sound happy puts her at ease, being so far away. However, there are a couple of places where she draws the line. The only restriction that my mom has on food is salt since it can aggravate Grandma’s hypertension. Another case is my Grandma's bathing. She takes great solace in being able to bathe by herself, despite having a tube attached to her body for dialysis. My mother and Uncle let her have that freedom. Their only concern is that if she has a fall, she will most likely break her hip or knee. After some time, they plan on getting her a caregiver who can help her bathe.

 

My mother has already consulted some colleagues about the prospect. My grandma was quick to agree to this. She knew that having a fall would immediately lead to her being bedridden, which, as everyone understood, was the last thing she wanted.

 

***

 

As for the option of a nursing home, my family knew that one wouldn’t be necessary because my grandmother was well enough to walk and didn’t need to be monitored more closely. In addition, the Philippines does have nursing homes, but they are not prevalent nor modern and safe as the ones here in the United States. Such facilities are also only affordable for few in the Philippines. Moreover, in the Philippines, it is typical for extended family to live in a house together. When a family member grows old, the other members look after the aging one. It’s an understanding that gets passed down through generations. My mom brought up my cousin Jean as an example: “Jean would definitely take care of his dad because of how Uncle Sonny takes care of Grandma. And Jean already knows that—he’s only twenty-two. But he was already telling me ‘I need to get a job because my dad will someday need me financially and morally.’ So at an early age, he’s already preparing himself.”

 

My mother makes it clear that it isn’t that the mentality of youth in the Philippines is more correct, simply different. “There’s this thing here that when you’re eighteen, you’re on your own. And at eighteen, on your own, you have to survive on your own. And the last thing that you have to worry about is your parents growing old, you know.” For example, even though my brother and I grew up here in the United States, we will most likely follow through with the plan that mom had with her mom.

 

Cultural difference in end-of-life care actually hadn’t been something that I’ve thought about very much. Growing up, I always had this understanding that I would be taking care of my parents when I grew older, and I still think that many young people understand that. However, after speaking with others about the matter, I can see how culture can make a difference in end-of-life-care. For example, Kei finds that patients that come from Asian, Jewish, or Italian backgrounds tended to have more family around when she did her home visits. Family structures can affect the dynamics of the circumstance differently.

 

***

 

At the end of the interview, my mom left me with this statement: “But I wish—my only regret—I wish I would be next to her see her day by day on her last few days.” Thankfully, things like Facebook and FaceTime make the distance a little easier. Before our talk, this was pretty much my understanding my mother and grandmother’s experience. Back when I still lived at home, I would sometimes wake up and hear my mother talking to Grandma or Uncle around 3 A.M. Of course, this had always been normal, but ever since I entered high school, I noticed the calls becoming more frequent. There were some days when my mom would tell me that she wished she could go home, but our exchanges never really went beyond that. That’s why, when I told her about my project, I was really surprised at how eager she was to talk to me about it.

 

A couple years ago, my mom flew home and threw my grandma a grand party for her 90th birthday. Family from all corners of the Philippines and parts of the United States came to celebrate their matriarch. Shortly after that evening, my mom posted myriad pictures of her smiling in a long teal dress. It was the first time I had seen her with makeup, and I had never seen her so happy for some time. Caring for a loved one far away is difficult. It involves a lot of communication, being available to talk when you can, but it’s not impossible. And when you are with that person, be sure to make to moments count.