The 75-year-old child

He raised his voice.

He pounded his fists.

His wife called his name and glared at him.

He pouted.

He persisted.

He interrupted.

He contradicted himself.

He had been forcibly removed by security a day previously.

He threatened to take me to court.

He was cornered and quite clearly out of his depth.

He was scared.

If I hadn’t let you know that “he” had a wife and was removed by security, you may have been mistaken for thinking that I was describing a petulant, stubborn and angry child.

But no, this was a 75-year-old man. And he was making our family meeting a little harder than it needed to be.

He was acting like a 75-year-old child.

One thing that I’ve learnt that diffuses childishness in adults is establishing clear boundaries — the rules of engagement, the sacred space of high-level decision making, the defining line of responsibility, ownership and choice.

Adult business.

And delivering this in a calm and rational manner using even-tempered speech is key. Unflinching and soft eye contact helps too. Keeping a still and steadfast posture and having an understanding that this behaviour is not personal to me is also very important.

But most importantly it is understanding that this is an emotional outburst with its roots in stunted emotional and psychological development which has been triggered by either fear, sadness or uncertainty.

This gentleman wasn’t going to get his way simply because he was sulking and raising his voice. It was very clear that in his 75 years he had not learned to channel his emotion nor had he developed a framework to deal with conflicting views and to take ownership over his actions.

See we aren’t talking about Happy Meals or icy pole flavours here, we are talking about significant end of life matters, which requires an adult conversation.

What I have seen over the last number of years is that the majority of families and patients will readily recognise the seriousness of these moments but some family members will selfishly make this about themselves by misbehaving.

It is clear to me that they are suffering. 

And it plain to see that what is happening to their beloved and loved is causing them deep unrest and distress. But as professionals, our work is in recognising this early, being compassionate and drawing clear boundaries around the safe space of whole patient care.

So calmly I said to this gentleman, “I can see that you are upset but when we speak in a family meeting, we do not raise our voice nor do we threaten one another. We listen, wait and then respond in a respectful manner. This is what we do when we are having an adult conversation”.

He fumed. Nostrils flaring, face reddening and the silence was deafening. So I continued, “if we have an issue with what is being said, we wait and then ask our question. Do understand what I am saying?”.

His wife immediately smiled at the corner of lips — I saw it. His older sister later thanked me, “Oh doctor, thank you! Well done!”.

So why do 75-year-old children exist?

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What it means to be an adult

Over the last year, I have been learning about what it means to be an adult — Thank you Jaemin.

Being an adult means to take full responsibility for all the decisions in our lives, to own all the consequences and to make the necessary changes and course corrections should we need to.

Adults are not co-dependent on others, needing them for constant emotional, psychological, social and possibly financial support. Adults are independent people who are in the driver’s seat of their lives, who have learned to meet their own needs. From this, they progress to inter-dependence, where as valuable contributors, they reasonably interact with others and make a difference in society.

Being an adult acknowledges the fact that other people do not control us and we are EXACTLY where we’ve chosen to be in life as a consequence of our own decisions. Adults see no need to blame or the need to take things personally.

“Adults take 100% responsibility, understand they have 100% choice and take 100% ownership for their results and actions”

– Jaemin Frazer

As a parent, I have two clear mandates — To raise three Ramachenderan men whose lives point to the truth and glory of the Gospel AND to raise three ADULT Ramachenderan men.

Simply because someone is chronological 45 years old, has a professional job, is married and has three children, doesn’t make then an adult.

There are many children masquerading as adults

I personally have had to do some deep work in my own life in areas where I was still showing up as a child in the way I was thinking and living.

Here are a few common signs that I see as a doctor of adults acting like children in my clinical world:

Picking and starting fights 
Inability to focus on another person (It’s about me!)
Spouse screaming matches 
Inability to take advice or constructive criticism 
Temper tantrums 
Constant sarcasm
Storming out or leaving a situation unfinished
Resorting to physical violence (or threatening it)
Inappropriate language and remarks 
Anger as the go-to answer for everything
Unreasonable requests
Inappropriate emotional outbursts
Inability to own mistakes or shortcomings
Blaming others for their issues

Wow! Do you know “adults” like this?

The key feature here is the failure to take 100% responsibility and ownership over their lives in developing into an emotionally stable and functional person who is able to meet their own needs.

Being an adult is primarily seen in how we show up to the world — taking responsibility and attending to setbacks. It isn’t losing your mind because something isn’t going your way — this is my tell-tale sign to look out for (as I’ve met a few children masquerading as adult surgeons).

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Now this gentleman was clearly losing his marbles. No one had pushed him but rather set up a safe space to discuss a few serious matters as adults.

I stopped the meeting to let him know that his behaviour was not acceptable.

Don’t get me wrong, this was, not an easy thing for me to do. I was raised in a South-East Asian culture which taught me that my elders were always to be respected and revered and thus taking a bold step to draw a boundary with this gentleman had my heart rate high and adrenaline pumping through my body.

This was a serious matter that needed to be resolved as it was causing our nurses and the medical team a great deal of distress. It required us to use a shared decision model and I advised him that if he continued in this manner, a decision would be made for him by the other cooperative members of the family unit. I held him in the space of being accountable for his behaviour. 

He told me that he was calling his lawyer and was taking me to court. 

“Focus Jonathan”, I told myself.

The emphasis of holding people to account is as follows.

“These are the rules. This is how we are going to proceed. If you cannot comply, this is what I am going to do”

Which is very similar to:

“If you throw that ball at your brothers or over the fence, you are coming inside”

“If you do not clean your room, you will not be coming for a bike ride” 

Or my favourite at the moment:

“If you do not finish your dinner, there is definitely no dessert”

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What I am learning is that 75-year-old children do exist, in fact, they are everywhere. For much of their lives, their family have had to endure and cover for them, making excuses for their terrible behaviour and their utterly poor decisions. “Yes, Dad has always been like that” or “he’s just not that good at doing those types of things”, “no I can’t talk about that with her, she will lose the plot”. Nope, I am sorry, these are examples of children masquerading as adults.

This is what Steve Biddulph had to say in his wonderful book “Raising Boys”. And please understand this is not specific to men.

“Developing maturity and character aren’t as automatic as physical development, a boy can get stuck.

Everyone knows at least one man who is large in body but small in mind or soul, who hasn’t developed as a mature person.

These men are everywhere, they might be a Prime Minister, President or Tycoon!

But you look at them and think, “Yep! Still a boy. And not a very nice one.”

Steven Biddulph — Raising Boys

This is how popular culture also captures adults who are acting as children from my favourite TV-show of all time, Seinfeld – episode “The Engagement”.

Managing the 75-year-old-children in your world

As a palliative care doctor, my work isn’t to run a simultaneous coaching session on “becoming an adult” alongside the important work of helping my patients with limited time on this earth. However, here are a few thoughts on how I have found a path to navigate this challenge. 

(1) Recognise dysfunction quickly — know the warning signs (see above) and recognise what you are dealing with. Detach yourself from any notion or feeling of this being personal attack on you — this isn’t personal, it’s an adult child.

(2) Rapidly and skillfully create a safe space for your patients, staff and the other reasonable members of the family unit by establishing boundaries.

Boundaries are the rules of engagement, the framework of decision making that adults use to reasonably solve complex people problems. Establish these early as the way “we do business”, making it clear to the adult child that it isn’t personal but how you and your team have always made decisions and management plans. 

See the one thing that I have learnt is that dysfunction hates routine. Dysfunction dislikes established systems and impersonal true and tested frameworks. In fact, the dysfunction dies as the adult child learns that “this is the way that we have always done things” because it breaks the personal nature that children associate everything with. 

See children believe that everything is about “me”, themselves. Everything is personalised and therefore viewed as an attack on themselves, from the big, bad, unfair, fun-spoiling parent.

For example, having a blanket rule at home that the Saturday chores must be done before playing on the Nintendo, BREAKS the personal nature of any appeal my boys may have. If the chores not done, there are no games. You can cry, you can wail, you can call Grandma on me, but Dad’s rule remains.

Similarly, in the clinical world when dealing with 75-year-old-children, establishing that what we are doing is required, routine and part of the evidence-based practice of medicine BREAKS the personal nature of “its all about me”.

Finally.

(3) Understand that it is usually suffering that is manifesting itself as a challenging person and engage professionals who are skilful in managing existential and psychosocial distress. 

This is the compassionate part of being human and recognising suffering. My job is not to pass judgement on adults who are acting like children but to keep them safe from harming themselves, others and me and my team.

There can be a tremendous amount of social, emotional and psychological unrest that surfaces as a loved one or a patient faces a life-limiting disease. 

Can you imagine the almighty clash and difficulty of dealing with your own or loved one’s mortality using child-like thinking? This is a HUGE assault on dysfunctional thinking and very predictably manifests as uncontrolled emotion.

Final thoughts

Children who are loved have boundaries established in their lives to keep them safe. They are then free to express themselves, live and love freely and explore the possibilities of this world. It is within this space that the journey to true adulthood begins as they start to make mistakes, upset and let down others and fall down a few or many times!

Children start to become adults when they start to realise the power of freedom in making their own decisions AND in accepting the outcome — good or bad. It is within this increasing responsibility of decision making and increasing ownership for meeting their emotional, psychological and physical needs, that they become adults! Hooray!

75-year-old children need boundaries. 

They need to be shown the rules of engagement, the expectations of behaviour and the decisions that are required from them. Anything else cannot be accepted because this opens the door to the chaos of their lives. My job as a professional is to hold the space of rational thought for them to operate in.

They can rant and rave, create disturbances, call lawyers and make it about themselves, but the adults in the room will continue on to make a shared decision until they are ready to re-engage.

Adults understand the gravity of decisions, their absolute freedom to make them and their acceptance of the outcome.

As health professionals, our job is to be skilful in the art of people and interpersonal relationships — this is Palliative Care, Health care and life in 2020.

Thank you.

Live intentionally.

Love relentlessly.

Enjoy your health and grow as an adult.

Dr. Jonathan Ramachenderan
@thehealthygp