Notes on Aging Parents

Mom still dances.  That is, she has an intricate schedule of what she watches on TV through the week.

One of her "Must Watch" shows is Tuesday at 9:00 AM, Dr Ray on EWTN.  He is a Psychologist who approaches issues from a Catholic/Christian perspective.  And he does not duck the hard questions.

Today's episode included segments with recent widows and their grieving processes.  Based on how Dr Ray handles delicate topics I think he would be a fair hand at making muffins. Stir just enough to wet the ingredients and get things going and then pop into the  oven.  It takes a deft hand to make tender muffins.

Four pages of Doctor Ray DVDs available.  Like I overheard in front of the cooler that holds craft beers, "It is only $15.  How bad can it be?"

Gummy Bears
Sometimes the little things make a big difference.  Dad was choking on his vitamins.  Somebody came up with the idea of microwaving them for a few seconds to soften them.  Now they go down-the-hatch without a problem.  I suspect the calories are doing him as much good as the vitamins at this point.

Hickory nuts
One of my eBay failures involved buying hickory nuts on eBay.  The seller claimed they were Shellbark Hickory nuts.  I suspect they are Mockernut Hickory nuts.  She-golly; what to do?

I have been putting them on the window sill where mom and dad can watch the city squirrels stealthily sneak up and take them.  Some times we get a treat and the squirrels eat them right there on the sill.

I had been using some of the nuts mom and dad put on their oatmeal but I could feel the distress of feeding human-quality food to animals.  After all, both mom and dad lived through the Depression.  They put half finished glasses of milk in the refrigerator so they can finish them in the morning.

I want to figure out a way to glue a tether to one of the nuts.  That should be entertaining.

Birds
I saw my first swallows yesterday.  The hummingbirds cannot be far behind.  I think mom and dad would get a kick out of having a hummingbird feeder just outside their window.

Pollen and allergies
This time of year is bad for allergies.  I think the problem is two-fold.  The most obvious reason is that there are a multitude of trees pollinating right now.  The other reason is less obvious.  The weather is so clement that the furnace and A/C rarely turn on.  Outside air infiltrates the house.  Without the furnace fan running there is no mechanism to filter the pollen out of the air.

I suggested that we run the fan for the next few months.  I estimated that it would cost about ten cents a day.  My parent's furnace has a killer filter on it.  I thought it made sense to make it earn its keep during the most pollen rich time of year...May and June.

Electrical receptacles
The electrical receptacles in my parent's house are very, very tired.  The plug on the coffee pot falls out.  And today, my dad's missile launching chair refused to launch, probably due to intermittent continuity.

You have to remember my parents came from an era when house fires were often caused by defective electrical appliances and gadgets.  They religiously unplug devices every night lest they wake up dead in the morning.  That is far more cycling than "kids" like me put on our electrical receptacles.

The wiring still has screw-in fuses.

I asked my dad for permission to replace the two most problematic receptacles.  He graciously agreed.  I did the deed.  Now that I have broken the ice I need to start replacing the other receptacles in the house.

Pill caddies

Photo taken through my eyes at 7:00 in the morning.

We had another near miss on meds.  I pulled the meds out of the pill caddy, put them into a cup and gave them to my mom.

She looked at them and said, "I think these are my night meds."  A quick check proved she was right.

Time to do something about it.

Green stickers were added to the PM med drop cubbies.

The night time med drop has less of an issue than the morning drop.  For one thing, the morning meds are gone.

We needed something very visual to make us stop and go "Hmmm!".

The local drugstore did not have more visual pill caddies but they did have round stickers.

If I were the manufacturer, I would consider labeling the PM cubbies in relief to make it visually much different from the AM cubbies.  It would not even require a different kind of ink.

Close tolerances and lots of moving parts

Mrs ERJ and I have been spending more than the usual amount of time with my mom and dad.

Dad's health took a turn for the worse a couple of weeks ago.  He had respiratory issues and then struggled to keep any kind of food or liquid down.

One advantage of spending more time with M&D, besides their delightful company, is that we could start to see patterns that had been opaque to us.

Dad's ability to retain foods had seemed random.  Some days were worse than others (clue #1).  In time it became apparent that he was better in the morning and went into the ditch at about 9:30 AM (clue #2).  There was dark granular material in his vomit (clue #3).  He had iron in his morning med drop three times a week (clue #4).  Iron supplements can cause stomach irritation and nausea (clue #5).

Iron supplements, photo taken from within my dad's stomach

We are running an experiment under the watchful eyes of my sisters who are nurses.  We are giving the morning med-drop later in the day so dad has more hours where he can retain food and liquid.  As retirees we can wait.  We are not in a heated rush to get out the door and to work.

We also pulled the iron supplement from the med drop.  So far, so good.

Dad is a bit leery of eating much.  If the iron was irritating his stomach then it may take a week to heal up.  Nobody else is in dad's body so he is the ultimate authority.

The great news is that he is now retaining a half bowl of oatmeal in the morning and a bowl of soup in the evening.  Not enough for him to retain body weight but WAY better than he had been doing.  Oh, and he has been holding down liquids...he starts his morning with three cups of coffee.  Oddly enough, coffee is one liquid he holds down well.  Sweet-and-cold drinks, not so well.

The bottom line is that it takes time to sort through issues.  Everybody had been pitching in to care for M&D so it was almost impossible to discern any patterns.

Also, if you are caring for aging parents, take the time to question every pill and medicine if their health takes a downturn.  Tolerance to meds and supplements diminish as kidney and liver function slow and as skin and stomachs can become less tolerant of insults. Fortunately, my family is blessed with a super-abundance of nurses and we even have a couple of doctors hiding in the family tree.

Fricassee

Mrs ERJ and I are still taking food to mom and dad on Fridays.

Dad's throat has become sensitive and foods that "tickle" going down trigger coughing and his gag reflex.  Smooth, easy-to-chew foods have become the order of the day.

Today we are taking mashed potatoes, fricassee and blueberry pie filling.

Fricassee is one of those dishes that used to be fashionable.  It is little more than meat cooked in gravy.  For my dad, the meat is thinly cut across-the-grain to make it easy to chew.

Wentworth and Smith

My dad was recently given my grandmother's arithmetic book from 1909.

A similar edition is online HERE.

Some of the questions:

It is notable that many of the examples are of people working.  Was the book a reflection of the times or was it deliberately seeking to inculcate cultural values?

Women's undergarments

One of the reasons I remain anonymous is so I can write little vignettes that would be excruciatingly embarrassing if anybody knew who I was.

I spent last night at my parent's home.  Dad had another episode of dehydration and falling.  His condition was exacerbated by a virus; swollen lymph nodes made swallowing more painful.

We thought he was going to be in the hospital a while.  The imaging showed all kinds of anomalies plus he was whistling and chuffing like a steam engine.

Finally, a doctor old enough to shave came on duty.  "Is he stabilized?"  Yes.  "Does he want to go home?"  Yes.  "Do you promise to drink two liters of water a day?" Yes.  "Men don't live to be 92 without getting scuffed up a bit.  Send him home."

So there I was patiently waiting in my parent's dining room this morning.  Dad was helping mom get dressed in another room.  Her arms don't have the flexibility that they used to. The doors were open in case one of them toppled and I was needed to help them up.  Even though I am not a total stranger to the sight of my mother's breasts, it has been fifty-eight years since I last saw them.  Mom was far more comfortable having dad help her get dressed.

It was reassuring to me to hear that my dad, at age 92, is just as baffled by the intricacies of intimate, female garments as I am.

Mardi Gras, 2018

I will be spending Mardi Gras with my mom and dad to give my sisters a break.

Dad is having dizzy spells and is more comfortable to have a "young" person (like me) around in case he falls.  My mom has osteoporosis and is not the steadiest of walkers.

Dad is a worrier.  He worries that one of them might fall in the night and the other might not hear them, especially since dad wears hearing aids and takes them out to sleep.

They both have pendants that can call for help but they are loath to push the button.  The last time dad fell it took him a couple of hours of crabbing backwards and resting until he could find a piece of furniture stable enough to help him get upright.

I will pick up a six pack of adult beverage on the way over.  I expect to only drink a couple of them.  It would not do for me to be the one who falls and needs help regaining his feet. 

Some old songs

My dad used to sing.  Most often it started was when the front tires of the '58 Plymouth station wagon hit a dirt road.  I don't think he realized he was singing.  Just him driving and the kids behaving in the back of the car.

This song captures the type of song and the (almost) a cappella delivery

Can she bake a cherry pie?

She'll be comin' round the mountain...

Put your head on my shoulder

Dehydration

My dad was not feeling great yesterday morning.

Since Friday mornings are when Mrs ERJ and I take mom and dad their meals we were in the driver's seat.

Two of my sisters and one of my sisters-in-law are nurses.  A quick texting conference settled on dehydration as a possible contributor to my dad's symptoms and it was the easiest, firstest thing to address.

Out came the 12 ounce water bottles.  We went with the smaller water bottles because they are easier for my dad to handle and because it gave the nurses more precision in measuring water intake.

Two went on the horizontal surface at the head of his bed.  Six more and a twelve pack of 7UP went into the fridge.

"Dad, I talked with the nurses and they think you might be dehydrated.  The plan is to have you drink from these bottles and for you to leave the empties on the table as you finish them so they can monitor how much you are drinking."  I said.

To my surprise he meekly said, "OK.  I can do that."

It is my impression that we become more susceptible to dehydration as we age and become more sedentary.  Our hunger and thirst signals become weaker.  We don't get hot and are not subjected to the same cues we received when we were more active.  Going to the bathroom becomes more of a chore and we eat and drink less to reduce the number of trips.

One way to combat that is to put out some water bottles and to have a schedule.  "OK, Dad, you need to drink one by nine, another by noon and the last one by four."

The caretaker puts out three bottles and at last check of the day there should be three empties.  The number and size of the bottles will vary, of course depending on the patient and their needs.

Dad perked up later in the day.  I don't know if it was the water or if it was due to the natural rhythm of how he was feeling.

A weekend of culture

We had a pleasant and uneventful weekend.

Yesterday we went over to Mom and Dad's to rake leaves.  It is a family event.  Dad can't quite keep up with the yard work any more.  The fact that he had his 92nd birthday last week might have something to do with it.  Danged party animal.  Still recovering.

He had a recent bout with low blood iron.  The most likely cause appears to be that tiny aspirin tablet he took every day.  Even though it was enteric coated it still allowed small intestinal bleeds to whittle down this iron reserves.

After raking, Mrs ERJ and I went to Grand Rapids.  Belladonna wanted to subject us to culture.  I think she wanted to hang out with us because her left shoulder is sore.  She thinks she has a slight tear in her upper pectoralis major...probably from dwarf throwing.

For whatever reason enormous numbers of dwarfs converged on the front steps of her townhouse on Tuesday night and she had a tremendous workout.  She thinks she might have over done things.

Stool samples.

The first museum we went to was The Grand Rapids Museum of Proctological Sciences.  Surprisingly, this is one of the very few museums of its type in the country.  In the end it did not appeal to my sense of taste.

Then we went to the Grand Rapids Art Museum which was, frankly, easier on the eyes and nose.  Every work of art had the admonition "Do not Touch!".  None of the exhibits at the GRMPS had those kinds of signs.

Mrs ERJ even got in trouble when she attempted to get the mobile that hung from the ceiling to move by blowing on it.  Perhaps it would have been less obvious if she had bothered to extinguish the cigar she was smoking at the time.

It caused Belladonna boundless mirth when this picture caused me distress.

It was painted by Mathias Alten and is titled "Birches in Winter".  Presumably it was painted a year before his death.

The thing I find bothersome is that the trees are very clearly American Sycamores, a tree that is very, very different than a birch.

I suspect they found the canvas when they were cleaning out his studio after his death.  Some low-level clerk at the auction house saw white bark and said "birch" catalogued it as such and the deed was done.

Otherwise, I find the art of Mathias Alten to be to my taste.  Big color.  Minimal fussy detail.  Solid composition.  Realistic looking people and animals.

One upmanship

A man died leaving three proud, competitive sons.

At his wake each one approached his coffin one at a time.

The first one made a big show of pulling out $10,000 in one hundred dollar bills.  "This is for you, Pops.  Have a great time up there!" as he stuck the bills in the coffin.

The second one pulled out $20,000 in one hundred dollar bills and said, "Dad, remember that I love you twice as much as Billy."

The third one approached the coffin, whipped out his checkbook and wrote a check for $130,000 and slid it into his dad's hand while scooping up the $30,000 in cash.  "Really going to miss you, Dad.  Thanks for all the life lessons."

Thresholds

The piece in the foreground is the 1.5" step that I tried to fix with the extruded aluminum molding.  Not only did my little brother knock it out of the park but he fixed the other side of the threshold where the step was about an inch.

And he also addressed the threshold between the back porch and the "coat room" of the house.

It looks like he used 5/4" Ponderosa Pine decking which should be good for twenty years.

Thanks for taking this on, little brother.  You did a GREAT job and Dad is happy.

ERJ calls in the Cavalry

My parent's house was built in the early 1920s and was not designed for elderly people.  When dropping off their meals last Friday my father mentioned, for the second time, the difficulties imposed by high thresholds.  The one that causes the most problems is between the ramp and the back porch.

There are times when my parents use wheeled conveyances to help with mobility.  My mother, in particular, is fond of a walker that has wheels that are about 8" in diameter.

My father described a very simple, wedge shaped molding.  The picture in his head, as near as I can discern, was to have a wedge that ramped up to the 1-1/2 step created by the threshold.

Mrs ERJ and I stopped by Home Depot on the way home and were not able to find any moldings similar to what my dad described.  We found many wedge shaped moldings but none that were 1.5" wide.

We did find an extruded, aluminum molding that I was pretty sure I could shingle over the existing threshold to smooth the transition.

The good news is that there was a step in the existing threshold and the top of the aluminum molding nested in it and the top surface was flush with the surface of the hard rubber threshold molding.

The bad news was that my parent's needs were not satisfied.

For one thing, the bottom of the door dragged on the molding.  Maybe not a big deal for you or me but not something my dad wanted to, or should have to deal with.  You can see from the rub mark depicted by the top arrow that the molding was hooking the door in the shut position.  I can just see my dad beating on the door in the winter time while standing on the icy, wooden ramp.

I think my dad might also have been wanting a gentler angle than was afforded by the aluminum molding.

Asking for help
I occasionally run with the pastor of a local church.  I asked him once, "When you look out over the congregation, what percentage is women and what percentage is men?"

He responded "80% women." without hesitation.

I asked him what he attributed the imbalance to.  He responded, "Men find it harder to ask for help.  Maybe it is because we are wired that way and we are socializing to be independent.  Going to church and praying is an admission that there are things that are beyond our control.  Women, in general, seem to be more aware of that than men and more at peace with asking for help."

I could see that I would really struggle to meet the needs of my mom and dad.  I lack the tools to do the job well.  I lack the skills and I rarely work on jobs that require that level of attention to detail.  I decided to ask for help.

I called my younger brother.  He gladly took on the task.  He said, "Joe, don't sweat it.  I got this.  I have a planer and I can custom make the ramp the way dad wants it."

But it is not just the tools.  He likes doing that kind of thing.  He is also the kind of guy who automatically cuts moldings with 0.7 degrees of back angle so the don't even show a hairline when he matches them up.  And he will probably use some kind of wood that will last until doomsday and look good to boot.

Thanks, Little Bro.

"Gram-maw? I am in trouble!"

Ring, ring, ring.

"Hello?"

"Gram-maw?  I'm in trouble!", kid's voice.

"Billy, is that you?"  'Gram-maw'. "Billy, I don't have my hearing aids in.  Can you text me?"  Gram-maw asked.

"Yeah, Gram-maw.  This is Billy.  I am in the jail in Chicago.  I swear I did not do it.  They are going to throw me in a cell with a bunch of drug addicts if I can't make bail?" 'Billy' texted.

"Oh Billy.  You scamp.  Seems like you spend a lot of time at the jailhouse.  Where did you say you are?  Mason? Charlotte?" 'Gram-maw' texted back.

"No Gram-maw.  I am in Chicago.  You have to wire me money or I am going to have to spend a week with the nastiest people you ever saw.  I am afraid all of them are gonna (in a whisper) rape me." 'Billy' texted.

"Oh my!  How did you get in this terrible mess?  Why didn't you call your dad?" 'Granm-maw' asked.

"I was driving and didn't know the guys in back were drinking beer.  The cop pulled us over when one of the guys flipped her the bird.  I swear, grandmaw, I wasn't doing nuthin."  'Billy' texted.

Grandmaw replied, "You know I can't see too good...but I am still mad at you for not sending me a picture when you graduated.  I don't suppose you could send me one of those suffies or what ever they call them?"

"Sure, Gram-maw.  Give me a second." 

Gram-maw texted, "Well ain't that something.  Look at how big you are.  How come I can't see the tattoo you said you were getting?"

Billy, "'Cause its on my chest."

Gram-maw, "Well, after giving you $1500 to pay for it I think you ought to send me a picture of that too?'

"Sure thing, Gram-maw.  It is on the way."

A couple minutes later.  "Yup, Billy, that sure is a beauty.  You know I don't keep that kind of money around the house but I can have it tomorrow.  Is there any way you can call me again?"

Billy, "I'm not sure.  What time are you going to have it?"

Gram-maw, "I reckon about 10:30.  I don't get up and around like I used to."

"OK." Billy.

****************************************************

Ring, ring, ring.

"Hello.  FBI."

"Hello Sharon.  This is Mrs D.V.  Can I talk to Billy?"

"You bet, Mrs D.V.  Agent Billy coming right up."

"Hi Grandmother, what can I do for you?" Agent Billy.

"I got another one of those calls.  He claimed to be my grandson named "Billy".  I did an inverse image look-up and he might be Omar al Sayood of Battle Creek, Michigan.  At least the owner of a Facebook account with that name looks exactly like him.  I also have a picture of his chest tattoo that he texted me. "

"He is going to call at 10:30 tomorrow morning.  Can you send an agent around for my cellphone...chain of evidence and all that?"

Agent Billy, "Sure thing, Grandmother.  Do you want us to try and whack him for fraud or embezzlement?"

Grandmother, "No.  My guess is that he is a recent immigrant.  I think impersonating a Federal Agent should be grounds for deportation.  Just because I am old, vote Republican and have a few dollars in my bank account doesn't mean I am stupid."

*****************************************

*****************************************

My 85 year old mom gets these kinds of calls on a frequent basis.  She worries that she might start to slip (mentally) and fall for one of these scams someday.  She says, "It is hard to tell for sure who you are talking to on the phone because all of the kids mumble now days."  I thought I would have a little bit of fun with how some of them might turn out.

Day in review

Lacking anything more interesting to share, I am going to give you an account of my day.

Video, smartphone, use it
I had a conversation with one of my nieces.  Her dad is going through some pretty heavy medical stuff.  The ERJ family has found that one of the more stressful times is when the doctor or specialist gives you that "brain dump" at 140 words a minute.

We evolved to where Kubota, our designated technical geek, is to activate the video record function of his smart phone.  He leaves it in his pocket and it records the audio portion.  Later, we can review it a hundred times (if we want) and look up words and phrases on the internet.  He leaves it in his pocket so the Doc is not intimidated.

Easy to do in the moment.  Impossible to do after the fact.

Estate sales
I popped into an estate sale today. 

I saw this but did not buy it.

A roofing hatchet with an 18" handle.  I bought it for $5.  Few things are handier when camping or when the zombies show up.

The handle is cracked but I think I can spread the crack enough to inject some adhesive.

Running

Belladonna is running.  Her personal conditioner "suggested" it would be good for her.  She HATES running.  For one thing, women have more moving parts than men (and that is the understatement of the year).  Part of what she has been doing this past week is trying to find a pace that does not put some part of her body into the Tacoma Narrows cha-cha.

Trying to be a supportive parent, I started running (again) too.

Few things are more conducive to long and deep sleep than running five miles, a plate of spaghetti and a couple of "rehydration" beers.

Where did the day go?

Hit-and-run
The gentleman I ran with today asked me for a favor.

One of their family friends is out of the country for a few weeks.  The friend's  sixteen year old daughter drove over to the house of one of her friends last night (St. Paddy's Day).  There was about an inch-and-a-half of sleet on the roads last night.  She left the pavement and hit a guard rail.  Good thing for the guard rail, otherwise she would have been swimming.

The way she told the story to my running friend, a part or two fell off the car.  My running buddy was tasked with collecting the part(s).  I have a truck.  He does not.

Based on the physical evidence that girl smacked the guard rail pretty hard.  The fascia (bumper cover) was ripped off the car and half shredded.  I suspect the left fender is toast, the hood wrinkled and the left front door creased.  I don't know the value of the vehicle but that might be enough to "total" it.

Oh, and the girl freaked and did not call the cops.

So my running buddy has to sort things out in the absence of the girl's parents.  One of the minor complications is that the accident occurred on a road that separates two counties.  Tradition has each county administering the accidents that occur on their side of the center line.  She lost control of the vehicle in one county but incurred the property damage in the other county.

Random picture

Seven or eight feet in diameter.  A big tree but not big for the species.

A very large Silver Maple, rotten to the core.  These trees are very vulnerable to ice damage as you can see from the broken-off limbs (stubs).  This is NOT a good species to plant for shade.  They grow fast and die fast and are hell on structures when they drop limbs on the roof.

Mystery solved: Why joints make noise as we age

We continue to take dinner over to mom and dad's on Fridays.  Today we took tilapia, sweet potatoes, grape-apple-yogurt salad and small cups of blueberry pie filling for dessert.

I clean dad's CPAP machine.

Mrs ERJ washes my mom's hair.

My mom's joints sound like a old, wooden ship in heavy weather as she gets out of her chair.  Those of you who are over fifty know what I mean.  And, according to my highly placed sources, it gets to be more and more of a chore to get out our chairs as we age.

She looked over at me and asked in her "school teacher voice",

"Do you know what that is the sound of?"

I shook my head "No".

"That is the sound of applause."

God bless you Mom, for being so positive.

Would YOU want to know the odds?

My brother was recently diagnosed with cancer.

Some folks think it is strange that he does not want to know "the odds".

I, however, think it is wise for many different reasons.

This is a "calibration" curve showing how most people process "odds" or "uncertainty".

The straight, green line that cuts across the graph diagonally is "perfect calibration."  That is not how folks intuitively process data, even ones that are highly trained in statistics.

The red, broken line more closely represents how people mentally "map" odds.  Most people are fairly well calibrated for 50:50 odds.  That is, the flip of a coin.

Most people are marginally calibrated for 25% and 75% odds.  When, in fact, the odds are 25% we treat them as if there was a 10% or 15% chance of occurring.  When there is actually a 20% chance of an event occurring we round down to 0%.  In a similar way, odds of 80% round up to 100% after being bent by our mental prism.

For all practical purposes that means that a patient who is told that their chances of survival are less than  20% will bend that information into certain doom.  They will lose the will to live.

Here is the pay-off line:
Based on the heuristics of how people process information: It would be more honest to dial in a little bit of Kentucky Windage and tell people with a 0.5%-to-20% chance of survival that they have a 25% chance of survival (which they will interpret as 10%-to-15% chance) than to than to tell them the mathematically defensible odds of survival (which they will morph to 0%).

But even that is misleading
To quote Gordon Dickson's Dorsai

Estimates had been...five percent (casualties) for the defending forces.  But such figures, without meaning to be, are misleading.  To the man in battle, twenty percent, or even five percent casualties do not mean that he will be five percent or twenty percent wounded... 

For life and death are binary.  There is no such thing as being a little bit dead.

Even if your odds of survival are one-in-a-million, iff you are the one...then you are still 100% alive.  The clarity of hindsight informs us that "your" odds for survival were 100%, just like the odds of that ovum being fertilized with that spermatozoon were 100%...in hindsight.

As a final consideration, consider the odds of a misdiagnosis.  Surely those odds are higher than 1%.

Healthcare practitioners
The game changes quite drastically for healthcare practitioners.  Doctors must use math to determine the course of treatment that offers the greatest benefit and the least harm.  Intuition is just not good enough.

Nurses must be protective of their own mental health.  Good nurses have an empathy bond with their patients.  "Knowing" that a patient might be dead in two months facilitates protective pre-grieving.  It also keeps the world orderly and sufficiently predictable to keep them from going bat-shit crazy.

The folks who are ripped to shreds are the doctors and nurses who are afflicted with cancer.  Perhaps even worse are the doctors and nurses who have close family who are diagnosed with the types of cancer that typically have 5%-to-20% survival rates.   Their professional training drags them one way.  The bonds of family anchor them.  What gives?

That is where we are today.  I have a brother with cancer.  I have a sister who worked as a nurse on the oncology floor for 25 years.  My sister lost her daughter in 2010 so she knows the agony of losing a child...and it tears her up when mom and dad ask her questions.  I have another brother who is a radiologist.  Actually, I have it pretty easy.

Bonus link on calibration and the appropriateness of extreme confidence.