Sunday, October 4, 2009

how Mom "decides"

Dad brought Mom out around 12:30 today-- early for Mom, given her frequent late awakenings these past couple of weeks. I was in the kitchen, preparing to have a simple bowl of cereal for lunch. With Dad next to her, Mom sauntered up to the bar and gave me a matter-of-fact look that she had perfected even before the cancer. In the BC (before cancer) era, the look could mean one of several things. Nowadays, it most often means, "Gimme food, boy."

So instead of whipping something up for Mom, I decided that this would be a good opportunity for her to practice her decision-making skills. With the loss of so much of her frontal lobe, Mom often needs help with making decisions and taking initiative. She's able to express when she doesn't want something, but has trouble verbalizing an active preference. (A lot of un-brain-damaged people seem to live their lives this way. What's their excuse?) For that reason, we have to do what we can to get the remaining functional parts of her brain to take over the executive functions that were shorn from her.

It's an exercise we've done a thousand times before: we present Mom with a decision, usually framed as "Do you want (to do) X or Y?" What usually happens is that Mom will remain silent for a period, then will drift away from the decision to concentrate on something else. Keeping her on track often means repeating the original question, but Mom's no fool: despite the brain damage, she's aware that we're trying to keep her on track, and if we re-ask our question too many times, she begins to show annoyance. We treasure the annoyance-- it's a reminder that Mom is still with us. But the process can't go on infinitely. If time's a-wasting, we eventually have to decide for Mom, because she hasn't bothered to decide for herself.

Today, then, I asked Mom whether she wanted kongnamul-guk or ddeok-guk (both of which I'd cooked yesterday; the ddeok-guk was originally ddeok mandu-guk, but the mandu were all slaughtered during dinner). Mom paused a long time, then gestured with her head toward my cereal. So-- not X or Y, but Z.

This was both unexpected and encouraging. Mom had seen that both Dad and I were planning to eat cereal, and she wanted to join in. So now we were at another crossroads: I took out four different types of cereal and displayed them before Mom. "Which cereal do you want?" I asked. I tapped each one, and with each tap said a number: "One, two, three, four."

Mom said nothing. Deciding from among four alternatives was harder for her. She stared and stared, then eventually shambled around to the other side of the bar, took one of the cereal boxes in her hand, and tried putting it away. At first, I thought that Mom was using this method to pare down her choices, showing me, through a process of elimination, that she wanted the Last Cereal Standing.

Alas, that wasn't what she was doing. When she got to the last box, Honey Nut Cheerios, she tried putting that one away, too. As she was awkwardly stuffing the box into the pantry cabinet, I asked her again, "Mom, which cereal do you want to eat?"

In a move that looked more like disgust at my persistence than anything else, Mom took the Cheerios back out and handed it to me. I decided to end the exercise there: Mom needed to eat, and it would have been silly to prolong this. Since Cheerios is what she handed me, Cheerios is what she got.

This is the sort of behavior that I'll want to discuss with Mom's neurologist. Part of me feels that Mom may actually have been trying to reach a decision, but her crossed wiring now prevents her from doing so in a smooth way. The behavior wasn't exactly perseverative, and the fact that Mom had enough initiative to suggest cereal instead of Korean soup was significant.

It's possible that the selection of cereal was done to avoid Korean soup as an option. As I mentioned, Mom is still capable of resistance/avoidance behavior: she often knows what she doesn't want, but can't express that fact unless or until she's confronted with the undesirable thing/option. But if Mom's "decision" was actually avoidance behavior... then what was she implying? That yesterday's soups were bad? I ask this only half-jokingly: Mom normally loves my soups, and yesterday was no exception: she ate all of her lunchtime kongnamul-guk, and most of her dinnertime ddeok mandu-guk.

Let's assume that she asked for cereal despite liking yesterday's soups. If that's the case, then we're looking at proactive decision-making, which is encouraging. Mom was "in a mood for" something other than the options presented to her; she already had an idea of what she wanted, but perhaps the idea hadn't crystallized until she saw Dad and me with cereal. Her head-gesture toward the cereal, then, was a move toward an option, not away from one.

If we don't assume Mom liked the soups, then we're pretty much left with avoidance behavior as an option. This is a plausible interpretation of Mom's actions, but now, the head-gesture acquires a profoundly different meaning: if it's a function of avoidance behavior, then it means that Mom is merely latching on to the first non-X and non-Y alternative she sees.

No matter how I interpret Mom's actions today, the behavior itself was unusual, and for the moment, I choose to view it optimistically. Today, I witnessed a glimmer of initiative.


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