Getting Old, Being Mortal

Atul Gawande's 4th book!

Atul Gawande — author (of three best-selling books - Complications, Better and The Checklist Manifesto), surgeon at Brigham and Women's Hospital in Boston, staff writer for The New Yorkers, professor at Harvard Medical School and Harvard School of Public Heath— is one of my favorite authors. Despite being a physician himself, he is forthright in saying that doctor's are not gods and astute in analyzing the odd triangular relationship of doctors, patients and medicine in general. His book Being Mortal is even more of an eye-opening analysis of the "problem" of aging, for that is how society now views it ... not aging as inevitable but more as a problem. He looks at the history of aging, perceptions of aging and how advanced medicine has changed those perceptions. This book must be read, shared, concepts discussed must become more than just concepts but must enter mainstream dialog, for by talking through our aging processes, Dr Gawande is showing that people are more accepting of the inevitable rather than undergoing massive amounts of medical treatments for extended life, but at what cost, longer life but one that has little value.

Points of awareness I want to retain:

The elderly in the US are classed by health care professionals as to what functions they can perform: 

• The 8 "Activities of Daily Living" - If you are incapable of doing without assistance — use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, walk — you lack the capacity for basic physical independence ... therefore nursing home care is required.
• The 8 "Independent Activities of Daily Living: - If you cannot— shop for yourself, prepare own food, maintain housekeeping, do your laundry, manage your meds, make phone calls, travel alone, handle your finances— you lack capacity to safely live on your own ... therefore, assisted living is required.

The teeth tell the aging story— experts say they can gauge a person's age to within five years by the examination of a single tooth (if the person has any teeth left). How? Teeth are the hardest substance in the human body, but with age the white enamel wears away exposing the softer, darker layers. Meanwhile, the blood supply to the pulp and roots atrophies and saliva flow diminishes. The gums become inflamed and pull away from the teeth, elongating the appearance, esp the lower ones.

To really know how an elder person is, always examine the feet! (p 40) Elderly can look dapper and fit but the feet tell the truth. Clipped toenails? Fungus? Bunions? Problems that cause poor fitting shoes, or shoes that are incorrect for posture, or injuries that affect walking ... which in turn affects hips and back being thrown out of alignment, or broken by pending falls. Can in fact the person touch his/her feet? 

A geriatrician should realize that aging of the body and the mind cannot be stopped; therefore, he/she should look at what functions the elderly have (like good shoes and proper foot care, and prescription medicines that don't, in combination, cause dizziness) and focus on prevention (like falls from floor mats and floppy shoes) rather than only giving prescriptions. 

Swallowing becomes a problem as people age. The lordosis of the spine tips the head forward, so when he/she looks straight ahead, it's like looking up at the ceiling for the non-aged. Therefore, for the elderly trying to swallow while looking up is a recipe for choking. The elderly might therefore need to eat while looking down.

Keren Brown Wilson, one of the originators for the concept of assisted living, built her first assisted living home for the aged in Oregon in the 1980s. In doing so, she was trying to eliminate nursing homes for the elderly and give them a home where they could age with autonomy, in other words, give them a "home". (In mind, she had her own mother who had suffered a debilitating stroke at the age of 55.) From there, the concept of "independent living" took off, but lacking Keren Wilson's vision for living with autonomy, assisted living residences only became an intermediate step before going to the nursing home.

(blog link - excellent read on Bill Thomas's audacious conversation to get the dogs, cats and birds)

Bill Thomas, of upstate New York, was a young physician that performed a radical experiment. In school he was "a pain", never studying, always questioning, and if the term had existed then, he would have been labeled as ODD - Oppositional Defiant Disorder. Ultimately, he connected to the idea of being a physician and did an about-face from not studying to studying and gaining entrance to Harvard Medical School. After graduation, he moved back to quiet upstate New York, eventually accepting a job at a nursing home, and with his glib tongue, wrangled the counsel members to allow him to bring in animals into the nursing home to give the residents, who had no inertia or desire to live, something to focus on. Not just a dog or a cat, but he started with 2 dogs, 4 cats and 100 parakeets. Residents were asked if they wanted a cage with parakeets in their rooms ... and the place came alive. People who didn't talk, took interest, named their birds, gave directions on the care of their birds, one man even came out of despondency, gained health again and returned back to his home to live by himself. The place was an utter success! According to research on the outcome, drug costs (mostly drugs for psychotropic agitation) dropped to just 38% and death fell 15%. Dr. Thomas writes about his experiment: Life Worth Living ... the Eden Alternative in Action.

The national Coping with Cancer project published a study that showed that caregivers of terminally ill patients who spent their last days in ICU were three times more likely to suffer major depression. In short, spending one's final days in ICU is like failure, failure to live life and pass with dignity as they are attached to ventilators, in delirium and permanently beyond realizing that they will ever return home.

People in the past died quickly, but in the present people don't want to accept death, and so extend life with medical "advancement", often compromising the quality just to obtain quantity. Examples of US presidents who died quickly:

• George Washington - throat infection one evening and died the next
• John Quincy Adams, Millard Fillmore, Andrew Johnson - had strokes and died within 2 days
• Rutherford Hayes - heart attack and died 3 days later

Not passing quite so quickly:

• James Monroe, Andrew Jackson - died from long-lasting tubercular consumption
• Ulysses Grant - oral cancer, died after 1 year

Mistakes doctors make are often conceptual. No one wants to admit that death comes. No one wants to sit down and talk directly about whether they want chemo or not, to be resuscitated or not, hospice or not. Basically, there's little to no discussion about facts and options. Doctors see themselves as prolonging life, and that image is often forced onto the patients and their families.

To discuss mortality with someone can be approached responsibly. According to palliative specialists, no one should say, "I'm sorry things turned out this way," which is distancing, but a preferably approach could be, "I wish things were different". And instead of asking, "What do you want when you are dying?" could be rephrased as "If time becomes short, what is most important to you?"