Caring for Nursing Home Patients under Medicare

What drove me crazy about practicing medicine in a nursing home wasn’t the patients, although with their many medical problems often including cognitive impairment they were a challenge; and it wasn’t the families, though with their anxiety and attentiveness and sometimes their guilt they were an even greater challenge. What drove me crazy about nursing home medicine was Medicare billing.

When I saw patients in the nursing home, I was hemmed in by the fact that Medicare had a very clear idea of what constituted an appointment with a nursing home patient. Continue reading…

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Why I Hope Not to Die at 75

I feel uniquely qualified to comment on Zeke Emanuel’s much-discussed article “Why I Hope to Die at 75.” I’m smack in the middle of the year he hopes will be his last. In addition, many years ago I wrote a book about health care organizational ethics with him (and Steven Pearson). I loved working with Zeke and admire the creative work he’s done on medical ethics and health policy.

Zeke says, correctly, that with limited exceptions, as we pass beyond 75 we typically lose physical and mental capacities, with the result, in his view, that “by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us, resulting in diminished productivity.” Although Zeke recognizes that we “accommodate [to] our physical and mental limitations” by diminishing our expectations and “restrict[ing] activities and projects, to ensure we can fulfill them,” at 57, he is horrified by the vision of diminution.

In Zeke’s view, to be remembered “framed not by our vivacity but by our frailty is the ultimate tragedy.” If a patient said this to me, I’d respond, “We can understand that losing vivacity and becoming frail is sad, but how can we understand why being remembered that way is ‘the ultimate tragedy’ for you?” Over the years, with patients who didn’t want to live beyond a particular age, we virtually always found highly personal fears underlying their picture of what the age meant.

We 75ers know from experience that Zeke has the facts right. I’ve experienced most of the changes he attributes to the age. But as is the case even for people who experience vastly more severe challenges than diminished aerobic capacity and declining productivity, most of us ferret out opportunities to contribute to the world and derive satisfaction. Many posts on Over 65 speak to this effort.

Zeke’s facts may be right, but what about the values he espouses? If Zeke were 17 his article would read as the exuberant outpourings of a brilliant adolescent. But he’s not 17 – he’s one of the leading bioethicists and policy experts in the world. As a result, rather than being understood for what he’s doing – presenting an unflattering view of himself in order to provoke thought in others, the Twitterati see him as telling others what values they should adopt. Even more foolishly, some claim that his highly idiosyncratic perspective, which I believe he will ultimately come to see as misguided, proves the truth of the “death panel” lie.

Many readers of Over 65 will agree with Zeke’s critique of American culture as too focused on the duration of life and too inattentive to the purposes of our lives. He calls this cultural type the “American Immortal.” But very few are likely to emulate his prediction that even if he is in excellent health at 75 he will decline all medical interventions except for relief of pain. No flu shots. No antibiotics for pneumonia.

If that view holds for the next 18 years, which I doubt will happen, I hope that when Zeke declines a flu shot or an antibiotic for a treatable infection his physician will be guided by “Four Models of the physician-patient relationship,” an article Zeke wrote in 1992 with his then-wife Linda. Here’s how they described the “deliberative model”:

“The aim of the physician-patient interaction [under the deliberative model] is to help the patient determine and choose the best health-related values that can be realized in the clinical situation . . . The physician’s objectives include suggesting why certain health-related values are more worthy and should be aspired to . . .” (emphasis added)

The values Zeke anticipates applying are not “the best health-related values” for a healthy 75 year old. It is not “worthy” to invite healthy life to end sooner than need be out of fear that we will be remembered as a frail elder, not as a vigorous youngster. That would be neurosis, not wisdom.

I mentioned above that I had the privilege of working on a project and writing a book with Zeke. I understood him to be a warm-hearted person and a gifted teacher who evinced respect and affection for a wide range of humanity quite independently of whether they were “creative” and “productive.” I believe the article he is being roundly attacked for is actually a gift. Zeke wants us to think seriously about what we value in life. By presenting views that many have found repugnant, and that I see as understandable but wrong, he’s achieving his purpose of provoking thought and discussion.

Zeke gives himself an out in the final paragraph of his long (5,000 words) article: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.” (I trust by that he means “as long as possible” in a state in which he can appreciate life and respond to others in a meaningful way.) I’m prepared to bet that when Zeke turns 75 he will no longer regard youthful vigor and stunning productivity as the only values worth living for. If I’m alive, I’ll look forward to his contributions to Over 65 when he hits that birthday in 18 years!

Jim Sabin, M.D., 75, is an organizer of Over 65, a professor of population medicine and psychiatry at Harvard Medical School, and a Fellow of the Hastings Center.

 

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Living in the Land of Limbo

This is not an impartial review. I’m a great admirer of Carol Levine’s work on family caregiving. Though we’ve never met in person, Carol has written seven terrific posts for Over 65. But despite my conflict of interest, I guarantee that if you read Living in the Land of Limbo: Fiction and Poetry about Family Caregiving, the book she compiled and edited, you’ll agree with me that it’s gripping and original!

The 35 stories and poems are organized into five sections based on the relationship of the caregiver to the person needing assistance: children of aging parents; husbands and wives; parents and sick children; relatives, lovers, and friends; and, paid caregivers.

The introduction tells readers the “story behind the stories.” Continue reading…

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Fathers, Sons, and Books

In November, 2012, I wrote a post about my mother’s hospice care. Mom died peacefully on January 6, 2013 at the age of 93. This post is about my father.

Over the past three weeks I have spent more “quality time” with my father than ever before. We have had a lot to review about both the past and the future. The last time we spent this much time together was in the mid summer of 1961 when the two of us hastily drove together from Waco, Texas to Columbia, South Carolina and back again on a mission to find a new home to buy in time for my siblings and me to start school. I was the recent owner of a driver’s license and could share the driving on a non-stop trip of a thousand miles in both directions. My mother demonstrated an enormous amount of trust when she let us pick her next home. The task was neatly accomplished; our new home exceeded my expectations and was just a few hundred yards from my new high school. The real payoff for me was the beginning of a new relationship with my Dad as a collaborator to accomplish something that would have been hard for him to do alone.

The last 18 months since my mother’s death have been very difficult for my father. Continue reading…

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Perry’s Graduation

My granddaughter Perry graduated from high school in June. It was a wonderful event on a beautiful day and she made us proud by winning a prize for her work in the social sciences. What made that event extra special was that she has lived with us for all of her 18 years, and this event was her first step toward leaving the family, going off to college.

Perry’s mother had died of a pulmonary embolism a day after her Perry’s birth in California where my son Peter was trying to make a career as a screen writer, a hard way to make a living. There seemed nothing else to do than to bring them home. Some six million grandparents help raise grandchildren, so there was nothing new to that.

But it was new to us, who had thought our nest had emptied years earlier. Continue reading…

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Seventy-five Year Old Doctors Talk about Death

Here’s what George Eliot wrote in Silas Marner about how the elderly contemplate the prospect of death:

“…it is often observable, that the older a man gets, the more difficult it is for him to retain a believing conception of his own death.”

I observed the opposite at my fiftieth medical school reunion in June.

In a multitude of conversations, and in the entries classmates wrote in our reunion book, we displayed a vivid “believing conception of [our] own death(s).” No one I spoke with was morbid. No one evinced fear.

The dominant tones were (1) matter-of-factness, (2) gallows humor, and (3) curiosity about the future of our species and planet. Continue reading…

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A Living Resume

On the occasion of my last birthday, a friend asked how it feels to be growing old? I proffered first, the old bromide that in my head I feelabout thirty, but my body groans a wholly different story. Then I joked that when people intone, “Well, you’re only as old as you feel,” I reflexively remark, if that’s true, then I’m really old!

Suddenly I found myself reflecting on my resume. Continue reading…

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Will guilt keep me from doing what is best for my Alzheimer spouse?

I met Vickie in Your Father’s Mustache, a sing-along place in Greenwich Village 46 years ago.  She had long dark hair and wore a poncho like Clint Eastwood in Fistful of Dollars. She was singing and swaying with such joy. She had the kind of face you could look at the rest of your life.  I noticed her eyes were different colors.  One was hazel and speckled with green, and the other a cloudy blue.  She asked me, “What do you do?”

“I’m a priest.”

She laughed uncontrollably.  That cinched it.  Continue reading…

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Robert Frost and the Decline of the Medical Profession

The title of this post is deliberately mysterious, but you’ll understand it at the end.

At my 50th medical school reunion in June, my classmates agreed that while the goals of medicine are as valid as ever, the profession itself is in decline. Here’s a quote from the Preface to our reunion book:

“A frequent refrain is our disappointment in the evolution of medicine in the 21st century…The art of medicine appears to have diminished in value.”

This isn’t just a reaction by grouchy old guys (my class, like other medical schools at the time, had relatively few women). In a recent survey of 13,575 physicians, 84% agreed that medicine is in decline, and 58% would not recommend medicine to young people. Continue reading…

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Dementia and the Goals of Care

Even though you think and behave perfectly normally, you might already have Alzheimer’s disease. In fact, you might warrant the label of “pre-clinical Alzheimer’s disease” for a full 20 years before graduating to the full-fledged condition. That according to the latest definition of Alzheimer’s put forward by the National Institute on Aging together with Alzheimer’s Association 3 years ago.

Heralded as a radical departure from earlier clinical diagnostic criteria, the new definition is in line with how we think about other chronic conditions such as cancer or heart disease. Normal cells often mutate into cancerous cells and proliferate for a long time before there are enough of them to produce symptoms—and a cancer diagnosis. Plaques may be deposited in the lining of coronary arteries long before they narrow blood vessels enough to impair blood flow to the heart resulting in chest pain. In all these cases, the hope is that we may be able to intervene during the pre-symptomatic phase, altering what is currently the inevitable trajectory of illness.

In the case of Alzheimer’s, detecting various “biomarkers” in the blood or cerebrospinal fluid would signal the need for some kind of biochemical intervention. The problem has been that we don’t as yet have any such intervention. Continue reading…

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