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7125. wonkers2 - 5/24/2007 3:06:56 PM Opinion All NYT
Opinion
Rethinking Old Age
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By ATUL GAWANDE
Published: May 24, 2007
At some point in life, you can’t live on your own anymore. We don’t like thinking about it, but after retirement age, about half of us eventually move into a nursing home, usually around age 80. It remains your most likely final address outside of a hospital.
To the extent that there is much public discussion about this phase of life, it’s about getting more control over our deaths (with living wills and the like). But we don’t much talk about getting more control over our lives in such places. It’s as if we’ve given up on the idea. And that’s a problem.
This week, I visited a woman who just moved into a nursing home. She is 89 years old with congestive heart failure, disabling arthritis, and after a series of falls, little choice but to leave her condominium. Usually, it’s the children who push for a change, but in this case, she was the one who did. “I fell twice in one week, and I told my daughter I don’t belong at home anymore,” she said.
She moved in a month ago. She picked the facility herself. It has excellent ratings, friendly staff, and her daughter lives nearby. She’s glad to be in a safe place — if there’s anything a decent nursing home is built for, it is safety. But she is struggling.
The trouble is — and it’s a possibility we’ve mostly ignored for the very old — she expects more from life than safety. “I know I can’t do what I used to,” she said, “but this feels like a hospital, not a home.” And that is in fact the near-universal reality.
Nursing home priorities are matters like avoiding bedsores and maintaining weight — important goals, but they are means, not ends. She left an airy apartment she furnished herself for a small beige hospital-like room with a stranger for a roommate. Her belongings were stripped down to what she could fit into the one cupboard and shelf they gave her. Basic matters, like when she goes to bed, wakes up, dresses, and eats were put under the rigid schedule of institutional life. Her main activities have become bingo, movies, and other forms of group entertainment. Is it any wonder most people dread nursing homes?
The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. She’s not alone. Surveys of nursing home residents reveal chronic boredom, loneliness, and lack of meaning — results not fundamentally different from prisoners, actually.
Certainly, nursing homes have come a long way from the fire-trap warehouses they used to be. But it seems we’ve settled on a belief that a life of worth and engagement is not possible once you lose independence.
There has been, however, a small band of renegades who disagree. They’ve created alternatives with names like the Green House Project, the Pioneer Network, and the Eden Alternative — all aiming to replace institutions for the disabled elderly with genuine homes. Bill Thomas, for example, is a geriatrician who calls himself a “nursing home abolitionist” and built the first Green Houses in Tupelo, Miss. These are houses for no more than 10 residents, equipped with a kitchen and living room at its center, not a nurse’s station, and personal furnishings. The bedrooms are private. Residents help one another with cooking and other work as they are able. Staff members provide not just nursing care but also mentoring for engaging in daily life, even for Alzheimer’s patients. And the homes meet all federal safety guidelines and work within state-reimbursement levels.
They have been a great success. Dr. Thomas is now building Green Houses in every state in the country with funds from the Robert Wood Johnson Foundation. Such experiments, however, represent only a tiny fraction of the 18,000 nursing homes nationwide.
“The No. 1 problem I see,” Dr. Thomas told me, “is that people believe what we have in old age is as good as we can expect.” As a result, families don’t press nursing homes with hard questions like, “How do you plan to change in the next year?” But we should, if we want to hope for something more than safety in our old age.
“This is my last hurrah,” the woman I met said. “This room is where I’ll die. But it won’t be anytime soon.” And indeed, physically she’s done well. All she needs now is a life worth living for.
Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.
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Past Coverage
National Briefing | South: Louisiana: Post-Hurricane Charges Dropped (April 26, 2007)
Oversight of Nursing Homes Is Criticized (April 22, 2007)
FITNESS; Shuffleboard Gets Pushed to the Closet (April 10, 2007)
Elder-Care Costs Deplete Savings Of a Generation (December 30, 2006)
7126. thoughtful - 5/24/2007 5:34:38 PM The situation has changed quite a bit with differing levels of care including assisted living which is much more home-like. Now there are places that offer a full range of living options that you can take advantage of as you need to. My MIL was in one such place that had private cottages, congregate living, assisted living and full nursing home care.
The level of care required by many of the people I know in nursing homes is appropriate to being like a hospital room. My MIL was in one for 11 years and it was the environment she needed. She was blind, very hard of hearing and unable to get around on her own. She had no sense of time and often didn't know her own son. Her roommate was a woman who was 100% bed ridden, didn't communicate or respond at all. For people like this, this is an appropriate level of care.
For people who have trouble living on their own but are still 'with it' there are assisted living places that provide apartment style living, lots of social activities for residents, communal dining to encourage social interaction and social activities scheduled. You can still maintain privacy and bring more personal belongings including furnishings.
Before MIL was in the nursing home, she was in a 'congregate living' place where she had her own apartment but went to the dining room for meals and enjoyed social events and exercise classes and so on with others. It provided no nursing care at all. She made friends and it was a great environment for her so long as she was able.
The beauty of these differing levels of care is that the less care you get the more affordable the living.
And as us baby boomers age, there will be plenty of businesses stepping up to fulfill our living needs, just like they did with giving us our beatles albums and our 1st homes. 7127. thoughtful - 5/27/2007 1:44:53 PM Trying to roll more legumes and beans into our diet, i made a 'mexican lasagne' last night that was delish and very easy. use 6 tortillas instead of noodles (i bought the multigrain) and spread a little tomato sauce in bottom of pan, then mix rest of tomato sauce (3 8oz cans in total) with 1 can of red kidney beans rinsed & drained, 1/2 green pepper finely chopped, 1/4c onion finely chopped, 1/4c sliced pitted black olives, 1t vinegar, 1/4t garlic powder, 1/2t oregano, 1/2t cumin, salt, pepper and mix well. Then layer in pan toritillas, sauce mix and shredded cheddar. Repeat 2 more times. Bake covered 20 min at 375 then uncover and bake 15 min more. Let sit 5 min before digging in. Yummy. 7128. thoughtful - 5/27/2007 1:49:05 PM My dear doc is retiring. I hope not for good. He's 55 and just had a baby. His wife is 50. I think she must have told him that she raised the first 4 kids...now it's his turn. So he's staying home to be a full-time dad.
Now i'm going to have to go dr. shopping. I hate that. It's so hard to find a doc who is willing to teach me, argue with me, and explain to me as well as put up with my strong dislike of medicine in general and my frequent use of unorthodox but natural cures if they do the trick. I've also been extremely spoiled as dear doc always gave us his e-mail and cell number so he was always at hand. How am I going to find a doc to do that?
Most frustrating. Maybe I can offer to baby sit while he tends to my family members???
7129. arkymalarky - 5/27/2007 2:55:58 PM I don't envy you the search. We got SO lucky when our doctor died this fall, but had his replacement not been so fantastic, we know from experience with Bob's dying father that there simply isn't a good choice where we live. The one I recommended to Bob's family, who seemed to do well with my grandparents, was absolutely awful--though better than what they had.
If things hadn't worked out for us, I'd be driving however far I had to go to get someone outside that town. If you have to drive, it would be worth it. Is it possible he could recommend someone to you who would suit your personality as a patient? 7130. arkymalarky - 5/27/2007 3:00:18 PM Um, we weren't lucky our doctor died, we were lucky his replacement was so great. 7131. alistairConnor - 5/27/2007 10:31:37 PM I'm facing the same problem too. Our family doctor for the past 18 years is taking more and more time off, as a prelude to retirement, i.e. she's not always there when we need her. She's been so good that I'm really perplexed at how to replace her.
All the more so because younger doctors are not willing to set up shop in country areas. They are not willing to do the irregular hours and the housecalls, they prefer comfortable suburban or city clienteles. 7132. wonkers2 - 5/28/2007 12:36:38 PM There is a long, excellent article in today's NYT on the causes, symptoms and treatment of strokes. It emphasizes the importance of quick diagnosis and proper treatment (within 3 hours for ischemic strokes) which most hospitals aren't equipped to provide and the importance of controlling high blood pressure to prevent strokes.
Lost Chances for Survival Before and After Strokes 7133. robertjayb - 5/28/2007 11:02:41 PM Kiwi cow gives low-fat milk. Chocolate next?
WELLINGTON, New Zealand: New Zealand scientists are breeding a herd of cows that produce lower-fat milk after the chance discovery of a natural gene mutation in one animal.
Milk from the cows is also high in health-boosting omega-3 fatty acids and makes butter that spreads as easily as margarine even when chilled, biotechnology company Vialactia said Monday.
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While she looked like any other Friesian cow, testing revealed that Marge's milk contained about 1 percent fat, compared with about 3.5 percent for whole milk.
Offspring from the cow also produce low-fat milk, showing the genetic trait is dominant, Snell said.
7134. robertjayb - 5/29/2007 5:37:51 AM Doctors group posts prices...(AP)
TORRANCE, Calif. (AP) - Breaking with long-held medical tradition, a Southern California physicians group has become one of the first and largest health organizations in the nation to make prices for procedures easily available to the public.
HealthCare Partners put an itemized price list on its Web site last week, with little fanfare.
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The Torrance-based company serves more than 500,000 patients, who can now learn without asking that a flu vaccine runs $15, a chest X-ray goes for $61, and a colonoscopy costs $424.
7135. thoughtful - 5/29/2007 5:57:14 PM wow! what a great innovation! bringing competition to the medical field.
All you'd need is catastrophic insurance for the biggies and then the price list for the regular procedures. Considering that I'd be looking at something in the neighborhood of $12-14,000 per year for health coverage for me and hubby for secondary, that would indeed buy us a lot of chest xrays, cholesterol tests and colonoscopies. 7136. wonkers2 - 5/30/2007 4:07:37 PM Health care pricing is a bit strange. The prices allowed by Medicare or Blue Cross are a small fraction of those for the uninsured man on the street. A friend of mine was able to buy a prescription item at Costco for $15 dollars that his Blue-Cross Blue Shield/Medco was charging, as I recall, something like $160 against his minimum/co-pay. He had the prescription filled at Costco and paid cash. He called Medco to find out what they were charging and got the run-around. They told him to call BC-BC where he also got the run-around. Finally, somebody at BC-BS told him what the price would be--ten times more than Costco's price. 7137. thoughtful - 5/30/2007 7:05:56 PM For those of you with pets...do the same thing with the vets.
I've gotten Rx slips from my vet instead of the drugs they like to dispense and have saved big bucks by going to cvs or walgreens with it. 7138. judithathome - 5/30/2007 11:42:49 PM Yeah, except my vet won't erite scripts. He fills them himself so he "knows what they're getting." Riiiight. 7139. wonkers2 - 5/31/2007 1:09:16 AM Seems to me that's unethical. I have to pry the prescription for eyeglasses out of the optometrist who checks my prescription, but he does give me a copy. Of course he wants me to buy new glasses from the selection in the store where he does the exams. 7140. thoughtful - 5/31/2007 1:39:42 PM I'm very open with my vets about what they charge. When the cat needed surgery, i price shopped it with other vets in the neighborhood, came back to them and asked them to justify their cost....which they did. But it was a wake-up call to them that there is competition out there and they need to charge accordingly. 7141. wonkers2 - 5/31/2007 3:12:04 PM Opinion All NYT
Opinion
The Obama Health Plan
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By ATUL GAWANDE
Published: May 31, 2007
As a surgeon, I’ve worked with the veterans’ health system, Medicare, Medicaid and private insurance companies. I’ve seen health care in Canada, Britain, Switzerland and the Netherlands. And I was in the Clinton administration when our plan for universal coverage failed. So, with a new health reform debate under way, what I want to tell you in my last guest column is this:
First, there is not a place in this world that is not struggling to control health costs while providing high-quality, easily accessible care. No one — no one — has a great solution.
But second, whether as a doctor or as a citizen, I would take almost any system — from Medicare-for-all to a private insurance voucher system — over the one we now have. Job-based insurance is bleeding away the viability of American businesses — even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a prescription or visit a doctor for a known medical issue because of cost.
My worry is less about what happens if we change than what happens if we don’t.
This week, Barack Obama released his health reform plan. It’s a puzzle how you are supposed to regard presidential candidates’ proposals. They are treated, by campaigns and media alike, as some kind of political G.P.S. device — gadgets primarily for political positioning. So this was how Mr. Obama’s plan was reported: it is a lot like John Edwards’s plan and the Massachusetts plan signed into law by Mitt Romney last year; and it has elements of John Kerry’s proposal from four years ago. In other words — ho hum — another centrist plan. No one except policy wonks will tell the proposals apart from one another.
Well, all this may be true. And if what you care about is which candidate can one-up the others, it is rather disappointing. But if what you care about is whether, after the 2008 election, we’ll be in a position to finally stop the health systems’ downward spiral, the similarity of the emerging proposals is exactly what’s interesting. I don’t think you can call it a consensus, but there is nonetheless a road forward being paved and a growing number of people from across the political spectrum are on it — not just presidential candidates, but governors from California to Pennsylvania, unions and businesses like Safeway, ATT and Pepsi.
This is what that road looks like. It is not single-payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre-existing conditions. They cover not just expensive sickness care, but also preventive care and cost-saving programs to give patients better control of chronic illnesses like diabetes and asthma.
We’d have a choice of competing private plans, and, with Edwards and Obama, a Medicare-like public option, too. An income-related federal subsidy or voucher would help individuals pay for that coverage. And the proposals also embrace what’s been called shared responsibility — requiring that individuals buy health insurance (at minimum for their children) and that employers bigger than 10 or 15 employees either provide health benefits or pay into a subsidy fund.
It is a coherent approach. And it seems to be our one politically viable approach, too. No question, proponents have crucial differences — like what the individual versus employer payments should be. And attacks are certain to label this as tax-and-spend liberalism and government-controlled health care. But these are not what will sabotage success.
Instead, the crucial matter is our reaction as a country when the attacks come. If we as consumers, health professionals and business leaders sit on our hands, unwilling to compromise and defend change, we will be doomed to our sliding global competitiveness and self-defeating system. Avoiding this will take extraordinary political leadership. So we should not even consider a candidate without a plan capable of producing agreement.
The ultimate measure of leadership, however, is not the plan. It is the capacity to take that plan and persuade people to find common ground in it. The politician who can is the one we want.
Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He has been a guest columnist this month
7142. thoughtful - 6/1/2007 2:20:30 PM Arky, on the thyroid board, someone posted an article suggesting that T4 supplement is more effective when taken at night than in the morning, in case that helps you at all.
7143. arkymalarky - 6/1/2007 6:16:58 PM Thanks! I'll ask my doctor about it when I go in the 11th. I wondered why they have you take it in the morning--whether they think it might affect sleep, or what. My parents take theirs once a day whenever they think about it, without regard to whether they have eaten recently or not (their doses are very different from each other).
While I'm here, an update (I know everyone's been dying of curiosity wrt my "program progress"):
I'm able to do a lot more already than I was, and I'm wrapping up the last project of a hellacious school year today (as I lurk in here), so I'll be focusing much better on my diet/exercise, with a lot more fruit and veggies than I eat during the school year. I'm also eating out way less and keeping better tabs on a food journal.
The basketball goal has been great, along with the other exercise I'm doing--more regularly now. With the allergy shots back on and being very careful about my antihistimine and controlling exposure, I hope to enjoy more outside stuff than I have in the past. If it bothers me too much I have plenty of stuff to work out with inside, including a nice treadmill and a stepper. I can also swim in my parents' pool. The town has a great paved walking/biking trail, too, and a nice recreation center with an inside walking track and exercise equipment. Since I have a class in town five days a week during June I can do any of those things before or after class whenever I want.
I'm sort of eyeing the end of June to see where I am in relation to where I was when I posted a few weeks ago, which was before I knew I had a thyroid problem, but at a point where I knew I had to do something to lose some weight and get some energy. At the end of June I'll post where I am healthwise. July 1 we're leaving for CO for at least two weeks (YEAH!!!). 7144. wonkers2 - 6/11/2007 1:36:29 PM A conversation with Dr. Death
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