No Sense, Lots of Dollars

Twenty-five years ago, discussions of medical futility were the rage in bioethics circles. The discussions petered out when it became clear that futility was in the eye of the beholder: physicians and patients often had very different ideas about what futility meant, depending on what they hoped medical treatment would accomplish.
   
In one case that generated considerable publicity, physicians sought to turn off the ventilator that was keeping 86-year-old Helga Wanglie alive. They argued that the ventilator was futile treatment since it would never allow Mrs. Wanglie, who was in a persistent vegetative state, to regain consciousness. Mrs. Wanglie’s husband, however, argued that keeping his wife alive—supplying the oxygen that her heart needed to keep on beating—was the goal of treatment. And by that standard, the ventilator was performing admirably. The court to which the physicians presented their case did not address whether the treatment was futile; it merely ruled that Mr. Wanglie was the rightful spokesperson for his wife and his wishes should be followed. Continue reading…

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How Patients Can Assess the Quality of Their Outpatient Care

Even before I launched my geriatric consultation practice, I found myself often poring over another doctor’s outpatient notes, trying to explain to a patient what the other doctor was doing.

Not every patient had questions and concerns about what their other healthcare providers were saying, and doing, but a fair number of them did. And family caregivers, in particular, were often concerned that perhaps their older loved one hadn’t been getting the “right” medical care.

These are, in truth, legitimate concerns. Busy doctors often don’t have the time to explain the assessment and plan to a patient and family. And in many cases, the care that clinicians provide may not correspond to best practice guidelines – if applicable to the situation – or to the patient’s preferences and values. Continue reading…

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Too Old to Drive?

On February 25, 1983, my mother drove out of the parking area behind the apartment building in Florida where she and my father lived. She suffered from gradual cognitive decline and should not have been driving. She didn’t notice an oncoming car and pulled in front of it. There was no initial sign of injury, but the next day she became acutely confused. The emergency room diagnosed a large subdural hematoma (bleeding between the skull and the brain). Twenty four hours later she was dead. Luckily the driver whose car she pulled in front of was unharmed.

What turned my mind to driving among over 65ers was my own recent experience of driving in the English countryside (Cornwall). Apart from the challenge of adapting to “the wrong side of the road,” the rural lanes – though beautiful – were narrow and curvy, with barely enough room for cars to pass each other. The thought “I’m too old to be doing this” entered my mind more than once! Continue reading…

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A Proposal That Just Might Solve the Primary Care Crisis: Meet the 35 Hour Work Week

In March, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.

Now, not everyone believes that a shortfall of PCPs is a serious problem.

However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed. Continue reading…

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Seamus Heaney

Learning, today, of the death of Seamus Heaney, I first thought of his magnificent essay  contrasting two views of dying, “Joy or Night: Last Things in the Poetry of W. B. Yeats and Philip Larkin,” in his 1995 volume The Redress of Poetry.  Heaney speaks of Larkin’s stark poem “Aubade” as “treating as mystification any imaginative or rhetorical ploy which might mask the facts of the body’s dissolution and the mind’s disappearance after death.” Continue reading…

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Learning from Our Elders

A recent phone call led me to reflect on how over 65ers can help younger folks learn about aging.

Three months ago I received a call from Langley Danowitz, daughter of Emily Lublin, a long time patient of mine, who had died in 2000 at age 84. (Langley had seen me quoted in a New York Times column. I use names with her permission.) Emily and I had a warm, friendly relationship and very much enjoyed working together on various vicissitudes of her 70s and 80s. At one point Emily said, “You have to promise not to retire before I die.” I was sad when she died, but happy to have been able to keep my promise. Continue reading…

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Making a Human Community

My wife Sidney and I spend our summers on a small island off the coast of Maine, Little Cranberry, well down east. The island has many charms, but I am most impressed by the wonderful integration of all age groups in the life of the island, from babies and young children to those in their 80s and 90s. Most impressive is that it includes teenagers, not an easy group to corral for adult activities, much less for hanging out with 4-year-olds and 85-year-olds. Continue reading…

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Irony, Resilience, and Late-Life Depression

I recently read two fascinating articles by Bill Randall, professor of gerontology at St. Thomas University in New Brunswick, Canada: “Aging, Irony, and Wisdom: On the Narrative Psychology of Later Life” and “The Importance of Being Ironic: Narrative Openness and Personal  Resilience in Later Life.” Two quotes convey the core perspectives I took from Randall’s essays:

“If innocence characterizes childhood . . . and earnestness is the mark of adulthood, with all its striving to make our way in the world, then irony, as an over-arching orientation, goes more naturally with later life, the stage in which, more than any other, we are confronted by the limits of our being and the fog of mystery that surrounds it.” (emphasis added)

“While it is true that many aging jokes are blatantly age­ist, many are enjoyed–if not generated–by older adults themselves. Such humor sup­plies them with a welcome chuckle and puts things in perspective. It helps them rise above their situation by mediating the message that age is not the unmitigated tragedy which, physically, it can seem. As such, it reaffirms their dignity by affording them an affectionate detachment from their infirmity and mortality.” (emphasis added) Continue reading…

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Music for the Aging Mind

“Music is the healing force of the universe”
-Albert Ayler, the late jazz saxophonist

Coincidentally or not, on the day after my last post, “Two Zorbas on Aging“, was published, I happened upon a column by Zorba Paster in the Lacrosse, Wisconsin Tribune titled “Patients need help with noisy hospitals,” that discusses a recent study in the Journal of the American Medical Association.

As Dr. Paster describes it, the study was of 400 ventilated patients in an ICU unit. Ventilators are known to be uncomfortable at best, and terrifying at worst. The silence of the patient necessitated by the ventilator is coupled with the noise of the unit. Given that scenario, it is not surprising that ventilation in an ICU is associated with agitation, anxiety, depression, and insomnia. Up to 25% seem to develop PTSD later on. Continue reading…

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Old Age and Autobiographical Memory

Encountering new research on autobiographical memory is always unsettling. Even if you avoid the frightening findings on Alzheimer’s and other pathological conditions, the unreliability and difficulty of aging memory are humbling. All of the errors of recall that beset the young become more pronounced in the old.

A well written and authoritative description of the burgeoning field can be found in Pieces of Light: The New Science of Memory by Charles Fernyhough. He is not only a noted young British researcher, but also a novelist; he enlivens the science by drawing on literature and his own life experiences to explicate the facets of memory research. His chapter on autobiographical memory and normal aging discusses his series of interviews with Nanna, his remarkably spry 95 year old Jewish immigrant grandmother. Continue reading…

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