We are exquisitely good at managing the aging emergency and strikingly bad at preventing it. That is a system design choice, not a clinical inevitability.
Every physician who cares for older adults knows the pattern. A patient we have seen for years, stable, independent, managing, arrives one day transformed by a single event: a fall, a hospitalization, a stroke, an acute delirium. And in the seventy-two hours that follow, a family that has never discussed powers of attorney, care settings, or goals of care is asked to make irreversible decisions at the moment they are least equipped to make them.
We treat this as bad luck. It is not bad luck. It is the predictable output of a system that has no slot for the conversation that would have prevented the scramble.
Consider how our workflows are built. A fifteen-minute visit optimized for the acute complaint and the medication reconciliation has no room for the sentence that changes everything: What matters to you, and have you and your family made a plan for when you need more help than you do today? We are reimbursed to manage disease and structurally discouraged from managing trajectory. So the trajectory manages the family instead, on its own schedule, which is always the worst possible one.
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The adult children who come to me for coaching are, almost without exception, intelligent and devoted people who were simply never told that a window existed. Nobody sat their parent down at seventy-five, while everything was fine, and said: This is the moment to name your agents, state your wishes, and build the bench of professionals you will eventually need, precisely because you do not need them yet. The legal window for these decisions closes when capacity does, and capacity often departs before anyone in the family has noticed it packing.
There is a clinical parallel we already accept without argument. We do not wait for the myocardial infarction to discuss cholesterol. We do not wait for the fracture to discuss bone density. Preventive medicine is the organizing principle of everything we do upstream of catastrophe. Yet in the domain of aging, function, and family decision-making, we have quietly accepted a purely reactive posture, and we have exported the cost of that posture onto exhausted daughters who find us in the emergency department instead of the office.
I am not naive about the constraints. The visit is short, the panel is large, the reimbursement does not reward the conversation, and many of us were never trained to have it. But I want to name what those constraints produce, because naming it is the first step to changing it. They produce guardianship petitions that a durable power of attorney would have prevented. They produce ICU standoffs that one health care proxy conversation would have resolved. They produce caregiver depression in the very family members who will make our patients’ next decisions. The absence of the early conversation is not neutral. It is a clinical event with a long tail.
What can we actually do inside the constraints we have? Small things, repeated, matter. A single question added to the annual visit for any patient over seventy-five: Have you named someone to make decisions for you if you could not, and does your family know your wishes? A referral reflex toward elder law and geriatric care management the way we reflexively refer toward cardiology. A willingness to say to the capable, independent seventy-eight-year-old in front of us: Now, while everything is working, is exactly when to do this. Not because anything is wrong, but because doing it now is the only version of this that stays on your terms.
The families I coach are doing heroic work in the dark because the lights were never turned on upstream. We are the people who could turn them on. The pre-crisis conversation will never be as satisfying as the save in the emergency department, and it will never be reimbursed as well. But it is, quietly, the most important appointment in geriatrics, and most of our patients will never have it unless one of us decides it is worth the ninety seconds it takes to begin.
Barbara Sparacino is a triple board-certified physician in adult and geriatric psychiatry and addiction medicine, and the founder of The Aging Parent Coach. With over fifteen years of clinical experience, she empowers adult children to navigate the emotional, legal, and caregiving complexities that arise when supporting aging parents. Her expert insights have been featured by major outlets, including NBC, Fox News, CBS, Apple News+, Style, Care.com, and Next Avenue.
Through her signature program, The Aging Parent Plan, Dr. Sparacino helps families make confident, values-based decisions about care while preserving their own mental and emotional well-being. She continues to practice psychiatry and teach through her work with the University of Miami and the Veterans Health Administration, advocating for a compassionate, evidence-informed approach to aging and mental health.
Follow her on Instagram, TikTok, or visit The Aging Parent Coach to learn more.
