Friday, March 13, 2015

Our time is coming ...

If I judged books by their covers, this one would be way up there. Fortunately Dr. Muriel R. Gillick, a staff physician at Harvard Vanguard Medical Associates and a Professor of Population Medicine at Harvard Medical School/Harvard Pilgrim Health Care Institute, has written a book worthy of its wonderful cover. The Denial of Aging: Perpetual Youth, Eternal Life, and Other Dangerous Fantasies shares her perspective on how we age in this country, focusing first on Medicare, then on the various living options for people who can no longer care for themselves, and ending with a call to the newly old and demographically enormous boomer generation to work for improvements -- improvements that will determine our own fates.

Here's a sample of Gillick's insights and blunt style:

Medicare is an excellent program-for the most vigorous of older people. It is no surprise that Medicare serves very robust elders well, since it was originally designed to provide coverage for older patients with episodic, reversible disease. It works beautifully for a person with an acute illness such as a kidney infection or gallstones, which typically requires a brief hospital stay and a short course of treatment -- antibiotics for the former and surgery for the latter.

But if Medicare is a good program for robust elders, it is profoundly inadequate for people who are frail or who are nearing the end of life. The reason for this inadequacy is that it favors institutional care over home care, it supports technology-intensive treatment rather than labor-intensive care, and it fails to provide adequately for chronic diseases. And people who have multiple medical conditions or are near the end of life fare best with care that keeps them out of hospitals, that helps them manage chronic illness, and that substitutes low-technology treatment for invasive therapy.

Our government insurance systems and the training of medical professionals conspire to rob elders of agency when we become frail (and most of us will.) Medicare doesn't pay for what many old people need to stay in their homes: occasional household help, perhaps to clean, do laundry or cook. Unless relatives step in, elders don't get help from the system until/unless they are sick or injured enough to require hospitalization. And Medicare doesn't cover long term nursing home care; for that, elders must become poor enough to qualify for Medicaid, the state program for the indigent. All of this means systemic preference for the most expensive ways of caring for old people -- and persistent calls to cut the burden to the taxpayer.

Doctors are ill-prepared to help old people hang on to what independence our bodies allow and to make choices that are in accord with our individual values and preferences. Everything about their training makes them aim to defeat disease and decay -- that's medicine's "dangerous fantasy" to which old people are too often sacrificed. Gillick believes it is the doctors job to help patients decide when enough is enough.

... the risk that geriatric medicine might lengthen life without improving its quality is real. The debate about whether existing approaches to care will lead to "compression of morbidity" in which the period of disability and dependence shrinks while overall lifespan grows, or instead to increasingly long periods of frailty, is far from settled.

This book with the wonderful cover was published in 2007. These issues seem to be getting more widespread discussion these days, post-Obamacare, in such works as Dr. Atul Gawande's Being Mortal and Dr. Angelo Volandes' The Conversation. Dr. Gillick continues her reflections at the blog Life in the End Zone.

I should add, if looking for conversation about and among elders, you might like Time Goes By.


Hattie said...

What worries me more is medical abandonment of very old and chronically ill people. That is what I have been seeing a lot of around here. Ronni has written about the shortage of gerontologists. It took us too long to get hospice for my mother in law. The medical professionals were just happy to leave her care to us and figured that solved the problem. This was burdensome for all of us,and we always needed more help than we got.
This is something to watch out for.

janinsanfran said...

The lack of gerontologists is something our generation will definitely face.

As for hospice: my FiL's death was eased by a good home hospice nurse, only involved for the last 4 days. On the other hand, my MiL was one of the few people who can be said to have exploited home hospice. She somehow talked herself in 18 months before she died; the various members of the team (none docs) repeatedly felt abused my her demands but agreed to cool off each time. My own parents never got any hospice care; I don't know that a hospice option was much developed in their location. Was that what happened for your MiL, Hattie?

Home hospice certainly seems the best of bad options, assuming we don't need so much care that we end up in some other setting. The increasing capacity of aggressive medicine to keep us going to the point that we can't just die is at the heart of what Dr. Gillick is recounting. Most people don't want that, but too many get it as incentives currently exist.

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