### The Journey of Resilience: A Reflection on a Broken System

The narrative of Carolyn Hebert and her spouse, a formerly dynamic, award-winning triathlete, unveils the harsh truths associated with aging, errors in healthcare, and the obstacles of pursuing empathetic care within a frequently impersonal system. Carolyn, a retired nurse, shares their journeys filled with sorrow but also the optimism that by revealing their difficulties, they can illuminate the systemic failures from which others may learn.

#### A Life Full of Adventure and Vitality

Carolyn and her husband enjoyed a fulfilling life characterized by resilience and adventure. Even in his late 80s, her husband maintained an astounding spirit, nurtured through years of dedication. Their shared passion for exploration led them to undertake nine trips in 2014 alone, exploring destinations such as Paris, the Hawaiian Islands, and London for the World Triathlon Finals. These memorable experiences epitomized the core of their united journey, showcasing their unwavering energy and zest for life.

However, as time moved on, their vibrant life began to shift, not solely due to aging but as a result of the systemic deficiencies that failed to respect her husband’s dignity and individuality.

#### Misdiagnosis and the Domino Effect of Assumptions

In 2013, Carolyn’s husband had a cardiac ablation procedure to treat atrial fibrillation (AFib), which effectively resolved the issue. Yet, years later, a new doctor misread his medical records, triggering a wave of significant mistakes. Although there was no indication of ongoing AFib concerns, the presumption that it was uncontrolled led to further incorrect conclusions.

This was merely the start. His naturally reserved demeanor, characterized by soft replies and occasional silences—traits he had consistently exhibited—was misinterpreted and culminated in an unfounded diagnosis of severe dementia and delusions. Despite the lack of corroborating documentation, this erroneous label profoundly altered the trajectory of his care, resulting in distressing consequences.

#### A Tragic Nursing Home Experience

The relocation to a nursing home, driven by his declining health and increasing care requirements, rapidly transformed into a horrifying experience. Rather than feeling secure or cared for, he developed an overwhelming dread for his safety—a fear that tragically was validated when he was strangled during his residency. Carolyn captured photos of his injuries and uncovered proof of weakened neck muscles that complicated swallowing. Even when she voiced her concerns, the facility and the supervising doctor dismissed them, leaving Carolyn helpless in seeking accountability. When she attempted to change the doctor in charge of her husband’s care, she was told she had no authority, highlighting the severe limitations imposed by systemic and bureaucratic obstacles.

#### Fear, Confusion, and Trauma

The situation intensified when her husband was abruptly taken from the nursing home to a hospital. Carolyn was absent during this critical time, and her husband, confused and frightened, could not understand the reasons for his transfer. This traumatic event culminated in a heart attack triggered by the stress and disorientation of such a sudden change.

In the hospital, he received a mix of treatments, including oxycodone for pain relief and Metoprolol for his heart condition. Unfortunately, a tragic complication arose: he coded due to these medications. This highlighted the precarious balance between pursuing aggressive medical treatment and addressing the crucial vulnerabilities inherent in elderly patients.

#### Mislabeling and Record Discrepancies

Compounding their issues was a shocking mislabeling of his health condition. Diagnosed with osteoporosis in 2012, a condition requiring careful management, his diagnosis inexplicably vanished when medical records were transferred after a van accident in 2019, with dementia mistakenly becoming the primary concern. These record-keeping and diagnostic inconsistencies underscored the flaws that afflict numerous healthcare systems, wherein lapses in communication can have extensive repercussions for patients and their families.

#### The Impact of a Disorienting Relocation

After choosing to stop driving in 2019, Carolyn and her husband transitioned to a senior living facility, primarily enticed by an attractive floor plan during a brief visit. What they could not foresee was the confusion resulting from the new setting. Although Carolyn had lived in the region decades earlier, navigating their unfamiliar surroundings proved challenging, complicating their adjustment to what was meant to be a safer and more supportive environment.

#### Reflections on a Broken System

In retrospect, Carolyn’s journey with her husband is defined by love, endurance, and adventure—yet also by deep sorrow and irritation. Her husband, once a vigorous and self-sufficient individual, faced indignities that no one should have to suffer. His decline was not merely a byproduct of aging but was hastened and worsened by systemic failures: misdiagnoses, dismissive attitudes, and a deficiency of personalized, compassionate care.

Carolyn’s narrative emphasizes the urgent need for reform within healthcare and elder care systems to guarantee dignity, transparency, and the right to personal advocacy.