Jazzman: Thank you so much for your story. It’s a great model.

* Dr. Gawande sounds – in tone and general manner a great deal like my family doctor as he’s dealt with my wife and children. That’s a high compliment – I think the world of Dr. Goldslach.

* It’s been some years since I’ve seen the man for my annual physical – time to change that.

* But first I’ll make sure my toenails are trimmed ..

Susan Leigh Deppe, MD, DFAPA
Board Certified in General Psychiatry and Geriatric Psychiatry

Faculty, The Silvan S. Tomkins Institute, Philadelphia, Pennsylvania
and
Clinical Assistant Professor of Psychiatry
The University of Vermont College of Medicine
Private Practice, Colchester, Vermont

As a nurse, the focus of my education and experience has been to look at the “big picture” in terms of treating the whole person. We have spent many hours at the bedside or in the homes of elders providing physical, emotional, and spiritual care to the individuals and their families. With further education and experience to become a nurse practitioner, we are able to work collaboratively with other providers to diagnose and treat illness as well as promote health and well-being.

I see us providing some of the care that young physicians are not choosing to provide as they seek to become doctors in more lucrative specialties. The quality of the care we provide has been shown to be on a par with that of physicians and I think our nursing focus adds an additional humanistic approach to the complex care of elders.

Another note: in the 1960s, I worked for a gereontologist as a college student at my university. They lost their funding…and I lost my job.

Like my mother-in-law, I’m sure that many compensate VERY well. Given enough information, they can answer your question with enough confidence (to you) that they know what’s going on.

I am very pleased that she is in a wonderful Alzheimer unit close to me, and my 4 year old son and I volunteer and play “crazy games” with the residents on the floor for 2 hours once a week.

They moved from a 9 room suburban house full of 50 years of accumulations (most of which was grudgingly divested) into 3 rooms. Last year a fall caused my mother to break several vertebrae and during the exploratory scans, it was determined that she had had many mini-strokes and the Alzheimer’s diagnosis of mental impairment was abandoned for a stroke model. Because we could not care for her in this condition she was sent to a nursing home for rehabilitation. Medicare would only subsidize the cost as long as she showed rehabilatory progress and then the allowed term was only for 3 months.

After 3 months she was to be transferred to a long term care nursing home from which her doctors said she would never leave. In order to be admitted to the nursing home she was required to forfeit all but $100K of my father’s and her assets to pay for the care. If she died before using up the assets, the balance would be returned to my father. Against her doctors’ advice we arranged for her to be returned to my sister’s house and pay for 24 Hr. private nursing care, which would more than halve the cost of the nursing home. My father continues to be active and my mother while wheelchair bound has actually improved mentally to a large degree by this arrangement.

The cost of elder care in this country could in many cases be reduced significantly by similar creative arrangements instead of the 1 size fits all plan that currently is in place. Suggestions such as Allison’s “adopt an elder” and many other alternatives are available but due to geriatric lobbying and vested interests and the medical industrial complex it needs bold leadership or a full blown crisis to affect the needed changes.

I personally have not patronized a Dr. (other than a dentist) in over 30 years, and have no plans to start unless I create a situation that is beyond my immediate control. I believe I am responsible for all my experience and believe I’ll manifest good health as long as it serves my purpose. If or when my purpose is no longer served by being healthy, I’ll cross that bridge when I come to it but unlike Marc McElroy I’m not planning on it.

Peace

And I see this among many parents of my friends: health and decline are their primary focus.

We now have a Boomer generation ill prepared for retirement, no meaningful savings, a fantasyland sense of healthcare and ‘feeling good.’ I think our generation is in for an even greater and worse shock because we think we can live (without planning) forever.

Who will take care of us? I dont see the health care system getting easier or more efficient for the elderly.

We don;t talk nearly enough about death and loss, an intense focus on preparing NOW for feeling healthier in old age. Aren’t we a society built on crisis? We think of treatment when our bodies begin to break but not before.

By the way i LOVED Dr. Gawande’s ‘Better.’

My sense is that within a few to ten years, there will be an anti-aging pill that will extend lives on average a certain degree – say ten to thirty percent. Not only will this be significant, but it will dramatically increase the focus on such research, leading to significant societal change (how will people view themselves, their work their familial relationships if they expect to live decades longer . . .?).

I would tie the conversation into the larger social dynamic. We are already sensing as a society how manipulable the body will be to the new technologies that are rapidly developing due to the combination of genomics, bioinformatics, etc. I see that feeling of empowerment as behind the very forward attacks on religion that have come out in book form recently (Dawkins, Dennett, Hitchens) – as what is God in the main but he who will welcome us after our death – when we finally fall to the ravages of age . . .. My sense is that the apparent focus of this program, on the massive aging of the baby boomer portion of the population, five years hence will be seen as not having looked around the bend of the curve in technology.

My Brazilian friend flatly stated, “in Brazil, you do not put your mom and dad in nursing homes. It doesn’t happen in my country.”

My Irish friend said, “they are more compassionate over there.” (Ireland)

Both agreed that “money, money, money,” is the driving factor in how Americans treat their parents.

Joshua it’s tough to lose a parent especially, I imagine, one so young. Even though we don’t know when out time will come- I think we think we are owed at least four score and ten. My mother’s mother in fact died at 62 from lung cancer. She did not smoke- but I think my grandfather did. he wasn’t around much – I think it was the coal burning in NYCity in those days. My mother sat by her mother giving her morphine to ease the pain on her death bed. I was about 6 years old at the time.

When I look at my mother’s body I see what happens when you live so long. She has little energy; she has bursts of it then rests. She can’t hear well or see well. There are bumps all over, on her head, on her back. She says she is like an old tree, gnarled and with warts. When I tell her to have the growths checked b/c it might be skin cancer- she gives me a blank stare. She says “everybody gets cancer don’t they?”. So much for that.

By the way she wears jeans and is very interested in fashion… always was. If she is going to go somewhere she is immediately planning what she will wear. If someone is coming over- she is beside herself about what to serve. This is what I mean about being interested in life. As well she reads the classics and pulls a volume of poetry off the shelf to read the lines she’s been remembering. She loves Wordsworth. She has an antique copy of the complete poems in tiny tiny print that she scrounged from somewhere.

Our lives are either too short or too long. I just don’t know what kind of “middle ground” is possible, even in a future of advanced medicine.

My mother refused the very strong push of the doctors which came with an equally strong warning about the suffering that she would go through if she did nothing. I had a hard time convincing her but she agreed to the petscan. The results indicated she should go for the biopsy and treatment. This time my mother dug her heels in. She wanted nothing to do with biopsy or radiation. We had arguments. Then I realized that she was telling me that she did not have the strength to go through that. If she did not want to go through this I figured she would not be able to go through it. What helped me was being able to Google information about needle biopsy of the lungs and radiation treatment. I finally understood my mother’s intuitive wisdom. The tests and the treatment would have upset her equilibrium, and have been very stressful physically and emotionally at the very least. This might have destroyed her will to go on as well since being independent is extremely important to her.

At that point mother turned on her doctors( it had been building), got angry insisted on a new doctor. She networked and found one. Her new doctor is a Russian woman in her 50’s, very sweet and caring, a pain specialist and trained in the Soviet Union, running a no-frills office in Brooklyn NY near where my mother lives. (There is quite a Russian community there.)

I was impressed. Her first visit was one hour and fifteen minutes (I go along). This is unheard of. Subsequent visits have been just as leisurely and focused. We made it clear –after presenting the doctor with the whole story and the medical records that my mother wanted palliative care. The doctor agreed and understood and after explaining all her options again. She even encouraged my mother. We agreed to take things as they come. The doctor said she would also make a home visit if it was necessary.

So here we are three years later. We have no definitive diagnosis, which can only be obtained with a biopsy, but my mother has had three more pretty good years, doing pretty well considering, getting more tired, including, at times being tired of living, more forgetful and mixed up but still trying to take care of herself. There are times when she really appears to be enjoying herself too- still very interested in life, sharing a little wisdom and being funny here an there. At the moment she and a friend are listening to soundtracks of the old Broadway shows, Rogers and Hammerstein, Lerner and Lowe ( My Fair Lady) that I sent her- and we are listening too now. She is making her way through Tony Judt’s book on postwar Europe at the moment. (Don’t ask her what it’s about when she finishes.)

I don’t know if I will live that long, but she is my model.

Oh yea, and he is lonely.

The good news is that he recognized the issue and checked himself into the Psychiatric ward two weeks ago. They prescribed him anti-depressants and he is already outside gardening again.

Moving forward, I hope the mental health of our elderly will be as much of a focus as the physical health. That includes fighting the stigma that is associated with taking these drugs – a stigma that might even be more prevalent in our golden agers.

In my vision, I’m still feeling good about life. That is, I’m not decrepid. I imagine most people hope for this. But I’m not sure that many focus their health care on preparing for it. I’m in my 40s now and face serious health issues – from poisoning, not natural causes or bad health habits – and I haven’t once heard any of the plethora of doctors I’ve been sent to in the last two years speak to me about how to help my body be in a condition to enjoy the elder part of my life.

Here, I will echo katemcshane, my naturopath and my acupuncturist do discuss these things. They think of the long-term impact of treatment plans and they approach a treatment plan as a path to health, not a management of illness. Is anyone seeing a movement towards this in the conventional medical institutions?

A random thought: perhaps it would be helpful to create a PR campaign that improves our perception of the value of elders; and then we can create adopt-an-elder programs where people offer to care for elders in their homes in exchange for the benefits of having an elder in the home.

Currently reading an old issue of Granta with a story by Helen Simpson, this line struck me:
“Prolongation of morbidity is what they’re calling this new lease of life after seventy.”
It recalls the “living with HIV” versus “dying of AIDS” lingo shift.

I still don’t buy the reductive notion that there is anything radically different to be done towards the very end that shouldn’t be done at an earlier stage of life to make the twilight brighter. After all, geriatrics is, says Wiki “the branch of medicine that focuses on health promotion and the prevention and treatment of disease and disability in later life.” Of course there are some new and greater challenges for health, but from how I read Gawande’s article, he is concerned with helping elderly people carry out their daily affairs without falling down or losing weight. The woman he wrote about had sturdy legs. This is probably because she was quite active and not sitting in front of a television for long hours. If she had practiced better eating habits (I’m speculating here), she may not have just gone in for mainly potatoes and would not have lost weight.

I’m looking forward to learning more about this.

In Gawande’s article, one of the geriatricians that he writes about spends a good part of his time with his patients looking at their feet. If the feet are in bad shape the elderly are more prone to falling. We all know that for many a fractured hip is the beginning of the end — Kurt Vonnegut died from complications from a fall.

Okinawa, Japan, which has one of the highest concentration of centenarians (42 centenarians per 100,000 people in 2003) provides an insight into the keys to a long, healthy life. Here is a link to the Okinawa Centenarian Study. The study mentions invariable factors, such as genes and climate, and many variable factors, such as diet, eating habits (less caloric intake), exercise, attitude towards life and integrative health care (Eastern and Western methods).