How We Manage Dying – I

It is challenging to write about death, but a blog on aging would not be complete without discussing it. I do not claim to be an expert on death and dying, and the following thoughts are from a composite of many people’s ideas including my own.

When I started medical school at age 21, I had virtually no experience with death. I had never been to a funeral or seen a dead person. In retrospect, it seems shocking, but death is so sanitized in this country, it is kept largely out of sight. My grandfather had died, but he lived 3,000 miles away.

In my first year anatomy class, I helped to dissect a cadaver, but this embalmed, sinewy being hardly seemed to have ever been alive.   Our focus was on learning the muscles, organs and bones. There wasn’t much thought given to whom this person was.

My first direct encounter with the death was on a Saturday morning when as an intern, (first training year after medical school) I admitted a lady to the hospital with severe congestive heart failure. She was terribly sick with extreme shortness of breath, severe edema in both legs and great anxiety from her breathlessness. Congestive heart failure is the result of damage to the heart muscle from any cause. The weakened muscle does not adequately pump the blood forward, and it backs up into the lungs and causes edema elsewhere. The patient was in severe distress, and since my supervising resident had gone home for the weekend, I called the senior resident on-call to come and help me decide what to do. Nowadays, there are powerful diuretics that can help the patient’s kidneys drain the excess fluid from her body and allow her heart to compensate, but the diuretics that were available at the time were relatively weak and ineffective to treat an emergency.

I was delighted with the resident who answered the call. He was someone that I looked up to and admired. He assessed the patient and thought that there was little that could be done other than to give her morphine which would allay her anxiety and sometimes improves congestive heart failure, potentially easing her breathing, Then he raced off to see other patients who needed him saying that I should do the best that I could. I was dismayed having been left on my own with this very sick patient. I gave her such diuretics as we had and administered morphine in a modest dose, which didn’t touch her symptoms. So, I gave her more morphine, hoping to find a dose that would make her more comfortable. After her third dose of morphine, her breathing slowed, much to her and my relief, but then she stopped breathing and died.

It was a shocking introduction to dying, and for a long time, I carried the belief that I was the cause of it, either because of my lack of knowledge of what else to do or because of giving too much morphine. After many years, I realized that what I did was an act of empathy. The lady was on the cusp of dying when she came to the hospital, and, in the absence of an effective treatment, what I did was to relieve her distress. At that time, CPR had recently come into existence, and virtually no one in a hospital was allowed to die without going through CPR as his/her terminal event. Trainees were taught that this was standard practice. Even though it was usually unsuccessful, it was done routinely. The health care culture operated on the principle that there is always something else that can be done. Death is a defeat.

In the mid 1960s, a different approach to the treatment of dying patients began to emerge; the concept of hospice was introduced in the United States. It was originated in England by a physician, Dame Cecily Saunders, and in 1963, she came to the US and started the first hospice unit in this country affiliated with Yale Medical School. In 1969, Elizabeth Kubler-Ross published her book “On Death and Dying”, which became a best seller, and in it she made a plea for allowing people die at home. She also testified to Congress that…

“We live in a very particular death-denying society.  We isolate both the dying and the old, and it serves a purpose.  They are reminders of our own mortality.  We should not institutionalize people.  We can give families more help with home care and visiting nurses, and so give the families and the patients the spiritual, emotional, and financial help in order to facilitate the final care at home.”

In 1979, congress funded an experiment with 26 hospices. Since then, the hospice movement has gradually spread throughout the country. Hospice operates on the principle that as one nears the end of life that the focus should shift from curative medicine to supportive care and comfort, including pain management, nutrition, counseling and facilitating the dying person’s last wishes. It has proven to be cost-effective and more satisfying for patients and family. To enter a hospice program and have it paid for by Medicare, one needs to discontinue curative treatments like cancer chemotherapy and have a life expectancy of six months or less.

Palliative care, a specialty that has grown quickly in the last decade, has a similar focus on comfort and quality of life improvement for patients with severe chronic diseases, but it allows simultaneous disease treatment and doesn’t have any time requirement.

So slowly the practice of medicine has incorporated practices and expertise that can make the end of life more comfortable and appropriate. Pain can almost always be managed, and the dying patient is generally more comfortable in familiar surroundings. Surveys indicate that up to 80% of people say they would prefer to die at home. So from my days as a trainee 50 years ago to now, we are slowly starting to realize as a society that there is a time when persisting with medical treatment really doesn’t do patients a service. We can’t escape death but we can make the time before we die more manageable.

Stress and Illness

It is a well-known phenomenon. A grieving wife or husband has a cardiac event and dies suddenly soon after the death of a spouse. We attribute this to stress as we do other physical breakdowns that occur at times of high pressure. Deaths are more common around major holidays or on the anniversary of a tragic event. How does that happen? Is it real? The facts are incontrovertible. We say, “He/she died of a broken heart,” and attribute it to stress.

There is increasing evidence that how we live our life is directly related to our health and longevity. Eating well, getting enough sleep, exercising regularly and managing stress are being shown in study after study to have important effects. The effects and mechanisms of stress have been more clearly elucidated in a recent article in the journal Lancet and summarized in the April issue of the Harvard Heart Letter. The study looks at the means by which stress brings about physical changes to our bodies.

The amygdala is an almond-sized area in the center of the brain that mediates our responses to perceived threats. The amygdala stores our emotionally charged experiences from the past and reacts instantaneously to events or situations that resemble them. It is this location in the brain that triggers an immediate response to perceived threats, including the “fright or flight” reaction. The amygdala can’t distinguish whether the threat is real of not, just that it looks like something it remembers to be threatening. When that happens, the amygdala lights up on brain scans indicating that it is actively processing the information and sending signals to other parts of the body.

Two areas that receive these signals are the hypothalamus and the pituitary gland. The hypothalamus signals one area of the adrenal glands to immediately secrete adrenalin, and the pituitary signals another area of the adrenal to secrete       cortisone. The adrenaline acts immediately, speeding up one’s heart, redirecting blood flow to the muscles and brain, and it triggers heightened awareness, dry mouth, increased sweating and it raises the blood sugar, all events that we associate with the “fight or flight” reaction. The body gears up for battle or to escape the threat. If the threat becomes longstanding, as with chronic stress, the secretion of cortisone increases over time, which has a number of deleterious side effects, like high blood pressure, stomach ulcers and malfunction of the immune system.

It has been shown in animals that chronic stress activates a third area of the body, the bone marrow. Stress activates the bone marrow to make and release white cells, infection-fighting cells. White cells are associated with inflammation, and inflammation encourages the buildup of fatty deposits in the walls of arteries, including the coronary arteries. So chronic stress in animals triggers a process that heightens the risk of coronary blockage and heart attacks.

It has not been known whether this same mechanism occurs in humans until the recent Harvard-Lancet study. The study, through the use of PET/CT scans of the brain, looked at the activity of the amygdala, the bone marrow and the presence of inflammation in the arteries and found that heightened activity in the amygdala was associated increased activity of the bone marrow, inflammation in the arteries and a higher risk of heart attack or other cardiac events. These findings confirm that stress has real physical consequences and helps to explain the mechanism. The amygdala helps people to sense and evaluate external stress and to mount an internal physiologic response. However, this response can be dysfunctional in people who are subject to sudden severe or prolonged stress or people who have higher levels of amygdala activity. How we manage our lives and what we feel and think has real consequences to our health.

What to do? Well, there is no glib easy answer. Ideally, if it is possible to reduce the stress by modifying your circumstances, that is the best answer, but very often this is not possible, at least not in the short run. Other methods of reducing stress are exercise, yoga and meditation. Walking, running, biking and swimming are all potentially good stress reducers. It depends on the person and what relaxes him or her. For some people, just getting out of doors for a period of time is enough to reduce the stress. It is highly recommended that you break up a long day with one or two short bits of activity. Even 15 minutes of walking or quiet meditation can lower body’s stress reaction.

Meditation has become a much more acceptable form of stress reduction. It was originally associated with certain religious practices, particularly Buddhism.   However, in the 1980s, Herbert Benson at Harvard Medical School discovered that by sitting quietly and narrowing your mental focus to a single thing (a sound [Om}, a word [peace}, or your breath) for 20-30 minutes each day that your physiology changes. Blood pressure lowers, muscles relax, and brain waves change from an alert pattern to a more relaxed state. It takes some practice to do this, and the alert mind tends to want to focus on the problems and thoughts of the day, but it can be learned with practice, and it has carryover effects to the whole day. There many classes that teach meditation, or as Benson called it, “the relaxation response”. The practice can also be called upon when facing a highly stressful circumstance. For example, I’ve had several MRIs in my life, and I have learned that when I feel claustrophobic to narrow my focus to my breath so that I can detach from the circumstances.

So in summary, stress has real effects on our physiology, potentially destructive effects if it goes on chronically. These effects are mediated through the brain, which activates hormones (adrenalin, cortisone) and inflammatory cells, which in turn negatively affect the blood flow to our heart and other organs. Learning means of managing stress is important to our health and longevity.

Falls In The Elderly

Injuries from falls are a significant hazard for older people, and often they are the precursor to significant decline in function. An NIH white paper on falls in the elderly had this to say about some of the consequences of falling:

Each year, more than 1.6 million older U.S. adults go to emergency departments for fall-related injuries. Among older adults, falls are the number one cause of fractures, hospital admissions for trauma, loss of independence, and injury deaths.

Fractures caused by falls can lead to hospital stays and disability. Most often, fall-related fractures are in the person’s hip, pelvis, spine, arm, hand, or ankle. Hip fractures are one of the most serious types of fall injury. They are a leading cause of injury and loss of independence, among older adults. Most healthy, independent older adults who are hospitalized for a broken hip are able to return home or live on their own after treatment and rehabilitation. Most of those who cannot return to independent living after such injuries had physical or mental disabilities before the fracture. Many of them will need long-term care.”

One-third of community dwelling elderly fall each year, and up to 60 percent of those residing in nursing homes fall each year. Falls account for over 90% of hip fractures, most of them occurring in people over 70. Falls are a marker of declining function and also the cause of declining function. People who fall have a greater functional loss, greater social and physical impairment, and a greater risk of institutionalization. Most falls occur in the home or in close proximity to it.

Over 50% of elderly who survive a hip fracture, are discharged to a nursing home and one half of those are still in the nursing home one year later. Falls are very serious contributor to physical decline in the elderly and are a significant cause of death.

There are many risk factors for falls. Some are the following:

Hazards in the environment particularly the home Muscle weakness and balance problems

Visual impairment


Medications (particularly anti-anxiety, sedative and anti-depressant)

Alcohol misuse

Poly-pharmacy (14% increase risk for every medication above 4 medications)

Confusion or cognitive impairment

Acute illness (such as pneumonia or urinary tract infections)

Neurologic disease (stroke, Parkinson’s disease or neuropathy)
Loss of consciousness for any reason.

Drop Attacks – Sudden collapse due to falling blood pressure, early stoke or heart problems such as arrhythmias.

It’s not unusual for more than one of these conditions to be operative in elderly individual, and a minority of people over 70 years do not have at least one.

Falls are obviously a serious threat to one’s health, mobility and independence. I have had two falls in the last year, probably contributed to by my Parkinson’s Disease. In one, I didn’t lift my foot high enough to clear a curb and fell on my left side. I was fortunate enough not to fracture anything, but I had prolonged pain from a muscle tear in my left hip. The other fall occurred when I was on a path and turned suddenly to look behind me, lost my balance and landed on my right side with much less in the way of injury. They were enough to make me pay attention when I am walking. No one whom I saw medically provided me with systematic counseling about fall prevention.

It is difficult to summarize what one should do to prevent falls. The list above is a brief summary of the factors to explore, but each of those categories has many subcategories for specific conditions. However, I believe that the primary factor that has to be overcome is mental. It is reluctance to admit that falls are a serious threat and to take action. I’ve watched my own procrastination in doing some of the things that obviously make sense. I now use a walking stick when I walk on an uneven surface, use a handrail when going up or down steps, exercise regularly for balance and strength and have started taking up carpets on which I could and have tripped, but I avoid using a cane which I probably should.

Here is a list of some of the common, general preventive measures for avoiding falls leaving aside treatment for specific diseases:

If you have fallen, talk to someone knowledgeable (doctor, physical or occupational therapist) about the specifics of your fall in order to focus your preventive efforts. If your fall involved loss of consciousness, this mandatory

  • Fall-proof your home.
    1. Keep small objects such as clutter, electrical cords or low furniture off the floor and out of walking paths.
    2. Throw rugs or small carpets should preferably be removed or have non-skid backing or non-skid mats. Use non-skid wax for hardwood floors.
    3. Stairs should be well lit and have handrails.
    4. Bathrooms should have grab bars in showers, tubs and by the toilet
    5. If you live in an environment where it freezes, be careful when stepping out of doors onto a deck or stairs, Sand or salt icy surfaces.
  • Exercise regularly. This should include exercises to improve balance as well as maintain muscle strength.
  • Be cautious about alcohol. Alcohol plus diminished inherent abilities can be a lethal combination.
  • Wear sensible shoes.
  • Avoid sedatives and tranquilizing medication that can alter your sense of consciousness. Work with your doctor to reduce the number of medications that you take. There is a 14 percent increase risk of falls for every additional medication above four. Be especially cautious with medication for blood pressure. These can cause of sudden drop in blood pressure when moving from sitting or lying to standing. Dehydration can cause the same phenomenon.
  • Have your vision checked regularly.
  • Be conscious of what you are doing. It is easy to do things suddenly assuming that your body will remain in balance while the reality is that you have lost the reflexes, strength or capacity to do so.

This is a quick tour of falls. Hopefully readers will better understand the potential seriousness of the problem and can avoid some of t he hazards discussed above.

Test post

This is a test posting to my subscribers.  The last posting, March 11 didn’t get distributed to my subscribers.   I think the problem has been fixed, but this is a test to see if it works now.

Another View of 80

A few weeks ago, I posted a blog that indicated some of my feelings about approaching my 80th birthday. Today I’ll share with you another person’s view of 80, that of Oliver Sacks, the neurologist and author.

Dr. Sacks writes, ” My father, who lived until 94, said that the 80s had been one of the most enjoyable decades of his life. He felt, as I begin to feel, not a shrinking but an enlargement of mental life in perspective. One has had a long experience of life, not only one’s own life, but others too. One has seen triumphs and tragedies, booms and busts, revolutions and wars, great achievements and deep ambiguities. One has seen grand theories rise, only to be toppled buy stubborn facts. One is more conscious of transience and, perhaps of beauty. At 80, one can take a long view and have a vivid, lived sense of history not possible at an earlier age. I can imagine, feel in my bones, what a century is like, which I could not do when I was 40 or 60. I do not think of old age as an ever grimmer time that one must somehow endure and make the best of, but as a time of leisure and freedom, free from the factitious urgencies of earlier days, free to explore whatever I wish, and to bind defaults and feelings of a lifetime together.

I’m looking forward to being 80.”

This was part of an essay written as he was approaching 80 years old. It was spoken by a man who knew that the end of his life was near. Years earlier, Oliver Sacks was found have a melanoma in his eye, and he wrote this knowing that the melanoma had spread widely throughout his body. He lived until 82 when he succumbed to his disease.

He retained his optimism and continued his writing until just before death. You may know that Oliver Sacks was a neurologist for some note. Aside from his last book, Gratitude, from which this essay was taken, Dr. Sacks wrote 13 other books, the best known of which were Awakenings and The Man That Mistook His Wife for a Hat. Awakenings was made into a movie with Robin Williams playing Dr. Sacks.

We all know that we are going to die at some point.   It seems to me that one of the challenges, if you are lucky enough to reach 80, is to really acknowledge that and come to terms with the inevitability of your death in order to move past it and focus on the opportunities that we still have to savor life. It requires living intensely in the present rather than looking ahead and anticipating the future. It’s the difference between waiting for the string to play out and investing in the possibilities that still exist.  The final chapters of life can be a very creative time if one doesn’t get bogged down anticipating the worst. It takes courage and discipline. Oliver Sacks embodied that.

Approaching 80

Approaching my 80th birthday is a psychological marker for me. It signifies that I have reached old age. This is completely personal. Not everyone views 80 as a marker. Actually, I read recently about an 86-year-old man who is still capable of running a marathon in less than four hours and about a 102-year-old man who completed a bicycle time trial averaging 17 miles an hour. That is truly remarkable, and there will be more people achieving results like that as life expectancy extends.  But for me. 80 signifies old.

I will reach 80 in a few months. I never expected to reach 80. The males on my father’s side of t he family all died in their 40s and 50s of heart disease, and I had coronary bypass surgery at 56, so I expected to be long gone. My experience will not be the same as others, although at some age, I think most will experience many of these feelings.  People age at different speeds, and some defy the norms. But for most of us, some point about 80, or slightly above, is a time of change in perspectives.

So, what does reaching 80 look like to me?

Well, it feels different from other birthdays. It is a point where it is difficult to deny that I am old and that I have some limited number of years left on this planet. Who knows how many, but it is probably a number less than ten. That’s okay. I doubt that it would be fun to live longer than that, but I feel exposed not having a decade between me and the hereafter. Nevertheless, I am starting to embrace my age; there is a certain pride in living this long. We live in such a youth-oriented culture that signs of aging are viewed as somewhat unseemly and something to be slightly ashamed of. Why else do we try so hard to maintain our youthful appearance and behavior? I am finally realizing that age, for all of its disadvantages, is something to be proud of.

As I’ve disconnected from my busy life of achieving and collecting, what I call the “noise of life”, and I have space to enjoy the perspectives and hopefully wisdom that comes with living a long time. I’m trying to get rid of “the shoulds” and spend my time doing the things I like or that challenge me in new and different ways. There is a constant temptation to fill all my time with tasks and activities that are familiar and that I know how to do. It is easy to fill a day or a week with chores, which I can do on automatic pilot and are not particularly satisfying. It has been necessary to release some of the things that have driven me and to tolerate the silence in order to find and create what comes next.

My time is sufficiently precious that I don’t have the inclination to carry grudges or to get angry at the things that I can’t control. It has always seemed good to me to accept people for who they are, even though I may not be attracted to some. (So far, our recently elected president is challenging that acceptance.) With people who are important to me, it seems much more sensible to respectfully say what may be troubling in the relationship and to avoid living in silent resentment. This can be difficult to do, and I’m not always successful, but at this point in life, I have only so much time to clear up misunderstandings and to express gratitude for the good things that have come.

I am confronted with the things that I just can’t do any more. Virtually everyone at 80 has some physical limitations. I love to be out of doors, to travel and see new things, to hike in the forest, and even to chop wood. Chopping wood would undoubtedly lead to days or weeks of back pain, and it just isn’t worth it. Hiking in the forest has to be calibrated with my Parkinson’s Disease to be confident that I can get back before I get exhausted. I’ve been fortunate enough to have had a lifetime of travel to exotic places, India, Africa, most of SE Asia, Bhutan, Nepal, South America. When my wife and I were traveling in the mountainous tribal areas of North Vietnam a couple of years ago, I became physically ill, and there was no doctor. It was not a serious illness, but it made me realize that I was at the end of my adventure travel. I need to be in places where there is reasonable medical care.

Whether we are extreme athletes or take more pedestrian risks, there are times when things don’t go smoothly or the unexpected happens. When that happens, one needs to fall back on reserve energy, strength and flexibility. People who climb mountains have told me there is no way to predict what will be encountered on a trip. They depend on the skills they have learned and physical fitness to find a way past their obstacle. To a lesser extent, unless one lives a very constrained life, our reserves of strength and experience allow us to explore the world with some confidence. For me at 80 those reserves are diminished.   There are things I would have taken on without thinking just a few years ago that I now need to carefully plan or forego for in order to avoid problems. In many ways, I am starting to understand the old person’s preference for predictability and routine.

Caution leads many seniors to live a severely constrained existence. One needs to find a balance between comfort and the thrill of adventures, no matter how small. I realize it is important to keep as active as possible and retain challenges even if modified to fit capabilities so that I don’t give up everything I enjoy. At 80, once you give something up, it is unlikely to come back. I’m lucky to have a supportive partner who encourages me and provides a safety net for trying new things.

At 80, I am no longer able to deny the presence of death. We spend a lifetime grappling with death in some way. When we are young, we ignore it. At other points, we are afraid of it. When we accept that it will occur to us, we wish that it will occur in a way that doesn’t involve too much suffering (not dementia, please).

Denial seems like a useful strategy for fending it off, but it doesn’t encourage coming to peace with one’s life, one’s accomplishments, one’s disappointments or with the people who really count in life. Preparing to accept death when it comes is a task of the elderly.

I recently saw the movie, “Fences,” in which the main character, Troy, sees death as an external force coming to get him. He challenges Death in his black robe with his sickle to come get him, and he is prepared to fight. I see death as more internal, as result of the inevitable struggle of a weakening body to deal with the challenges of living. If we are lucky enough to live until 80, death is a natural process of the wearing out of a machine. Plus, death is what makes life so precious. I think of the efforts of millennia to find the path to immortality. Major current research is devoted to extending life indefinitely. I think that it would be a bit boring after 100 years or so to keep hanging onto life. Knowing that it is all going to end motivates me to try to squeeze as much juice as possible out of the present and gives me the courage to try things that I might not do if I had infinite time.

“When signs of age begin to mark my body

(and still more when they may touch my mind),

when the ill that is to diminish me or carry

me off strikes from without, or is born within me,

when the painful moments come,

when I suddenly waken to the fact that I am ill or growing old,

and above all at the last moment when I feel that I am losing hold of myself

and am absolutely passive in the hands

of the great unknown forces that have formed me.

In all those dark moments, O God,

grant that I should understand that it is you

(provided only my faith is strong enough)

who are painfully parting the fibers of my being

in order to penetrate to the very marrow of my substance

and bear me away within yourself.”

Pierre Teilhard de Chardin

Senior Living Facilities


One of the worst fears for many people is that they will end up in a nursing home. If you are over 60, you probably have at least thought about whether at some point, you will have to move into a community designed for seniors. More often, this consideration occurs because something has changed, making living independently in you own home more difficult. It could be triggered by the death of a spouse or an illness that makes it difficult to function alone, or it could be due to advancing age and infirmity. Most people, like myself, don’t want to think about such a possibility, preferring to assume they will stay in their home, and consequently until the decision is thrust upon us don’t think about it and don’t know what alternatives there are. Fourteen percent of working people think they are likely to need such services at some point. In fact, sixth-six percent do.

What follows are brief descriptions of the major alternatives that represent different needs and levels of care.   It is useful to know the choices whether for yourself or a family member or a friend. If nothing else, it is worth being acquainted with the vocabulary. The choices are arrayed from the least intense to the more intense services.

Senior Communities: These are residences set up for seniors. They may be arranged as town houses or as an apartment complex. They are appropriate for relatively independent seniors who are ambulatory and have little in the way of disability.   Often, they have recreational facilities, such as a gym or swimming pool, and they may offer services such as housekeeping and dining, but they don’t offer nursing care or help with “Activities Of Daily Living” (ADLs such as independently ambulating, dressing. bathing, self feeding, personal hygiene and grooming, toilet hygiene and continence). Therefore, these communities are for high functioning seniors, who will have to move elsewhere if they become unable to care for themselves.

 Home Health Care: Home health services are adjunctive services that can be brought into a home of someone who is unable to travel to receive care, and which are essential to a person who wants to remain at home rather than in an institution. The services are generally adjunctive to the care provided by family or friends. They include, intermittent skilled nursing care (such as physical evaluation, wound care, IV administration), physical and occupational therapy, speech therapy, medical supplies and devices. Medicare parts A and B will pay for most of these things. Medicare does not pay for 24-hour home care, meals, homemaker services (laundry, shopping, house cleaning, personal care). To receive Medicare coverage, a doctor must certify that the person is housebound and must order the services, and the nursing services must be intermittent, not continuous. Often, home health care is supplemented by a home health aide who takes care of the more custodial tasks and is paid by the patient or family. Other services that can be added to home health services are senior day care centers, meals on wheels and senior transportation services.

Assisted Living Facilities: For some, it may be too expensive or difficult to remain at home. In the last two decades, there has been an explosion of alternative care facilities, sparing seniors the agonizing choice between home and nursing home. The alternative is an Assisted Living Facility where the person can live in a group setting in which they have a room and can get assistance with ADLs, such as dressing, bathing, grooming and has someone available on site 24 hours a day. The individual must be ambulatory and generally takes meals in a communal dining room. The facility usually provides services such as house keeping, shopping, assistance with medication, ambulating outdoors, but does not provide medical or nursing services. Board and Care facilities are another form of Assisted Living, but it is provided in a private home.

Skilled Nursing Facility (SNF): SNFs are one step up from assisted living and one step down from a hospital.   In fact, a SNF is often used following a hospitalization as a transition to going home. A SNF can provide full time nurses, a doctor who rounds daily. In addition to help with ADLs, they can provide medication management, wound care and a variety of rehabilitation services such as physical therapy and speech therapy. The differences between Assisted Living and a SNF is the availability of these nursing and rehabilitative services. Medicare provides coverage for a SNF, for up to 100 days after an acute hospitalization.

Nursing Homes: What is the difference between a SNF and a Nursing Home? Unfortunately, the terms are sometimes used interchangeably. In fact, some facilities may have both SNF and nursing home sections. Basically, a SNF must be licensed by Medicare and usually meets a higher standard of care than that required of a Nursing Home. Nursing homes are usually licensed by the state. Nursing homes are staffed by nurses and nursing assistants who can provide assistance with ADLs, meals, medication and management of minor wounds and catheters.   Generally, they provide care that a healthy person could manage on their own. They generally don’t provide rehabilitative services or care of more complicated problems. A nursing home may be the permanent residence of handicapped (physically or mentally) or frail individuals, and such is considered to be “custodial care”. The cost of a nursing home can run $100,000 to $200,000 per year depending on location and the facility. Medicare will not pay for custodial care. Medicaid will pay, but the person must spend down their financial resources to qualify for Medicaid.

Continuing Care: These facilities provide multiple levels of care, independent living, assisted living and skilled nursing, and a person moves up the scale as they age and need more care. They generally require a person to be independent when they enter. They are a good choice for someone who is still independent and wants the security of knowing that they can remain in the same facility when their needs become greater. These facilities usually provide various forms of recreational facilities, meals and transportation. They are expensive and not affordable for most. There is usually a substantial fee to buy in ($100,000 to $1,000,000, depending on what is covered, the desirability of the location and the facility) and a significant monthly charge ($1,000 to $6,000).

Other resources:  Long-term care insurance is a policy usually purchased while one is working, which will defray a proportion of the things not covered by Medicare.  Aging Life Care Professionals, or Geriatric Care Managers, are individuals who are expert at knowing the resources available in their geographic area. They can help guide a client and/or their family to the local resources, examine the alternatives, help assess costs and be an ombudsman for the person involved. If they have been certified as an Aging Life Care professional by the ALCA, it guarantees a level of knowledge and training.

Obviously, this is a cursory look at a very complex subject. It is a starter kit. If possible, it is worth consulting with an Aging Life Care Professional if one is in the process of considering alternatives.

Views Of Aging

For this posting, I thought that I would share some of the pithy quotes that people wiser than I have written. Enjoy.

“You don’t stop laughing when you grow old; you grow old when you stop laughing”.     George Bernard Shaw

“And the beauty of a woman with passing years only grows”.                                    Audrey Hepburn

“Your face is marked with lines of life, put there by love and laughter, suffering and tears. It’s beautiful”.                                                                                                             Lynsay Sands

“I wish the time hadn’t gone so fast. And sometimes I wish that that I had enjoyed it more along the way and worried about it less”.                                                                         Neil Gelman

“I’m not opposed to aging – though society is kinder to men than women when it comes to growing old. How can I look at aging as the enemy? It happens whether I like it or not, and no one is set apart from growing old; it comes to us all. Youth passes for everyone, so why deny it? I’m proud of my age. I’m proud that I have survived this planet for as long as I have, and should I end up withered and wrinkled and with a lifetime of wisdom, I would trade a few years of youth for the sophistication of a great mind.. for as long as it lasts”.   Donna Lynn Hope

“We don’t age out of singing or eating ice cream, why should we stop making love”?Ashton Applewhite

“Stop whining about getting old. It’s a privilege”.                                                             Amy Poehler

“No age in life is inglorious. Youth has its merits; living to a ripe old age is a true statement of value. Aging is the road to take to discern our character. Fame and fortune may elude us, but character is immortal. We must encounter a sufficient variety of experiences, including both failure and accomplishments, in order to gain nobility of character”.       Kilroy J Oldster

“If we counted wrinkles like pages in a book, some of us are fast approaching ‘epic’ status”.                                                                                                                             Jo Ann V Glim

“When Dr. Jung said we must be able to look forward in old age to the next day, and to look forward to the next adventure that is ahead, he was stating life’s imperative, to grow, personal. As long as we are alive, we must be able to dream of the future, of better ways of life. We are also invited by our better Self to dream new dreams of creativity and fresh ways of expressing ourselves, as many great artists have into their nineties”.                 Bud Harris

When you are distressed with your aging and want to go back to your youth, think of algebra”.                                                                                                                   Unknown

“None are so old as those who have outlived enthusiasm”.                                         Henry David Thoreau

“Grow old with me, the best is yet to come”.                                                               Robert Browning

Genes: Masters of Health and Disease

The science of genetics has changed so much over the last 50 years that it is hardly recognizable to someone like me who took my last genetics course in medical school. At that time, we were taught that an individual’s basic characteristics are inherited from his/her parents by means of genes that are carried on 23 pairs of chromosomes, twisted strands of DNA that carries the code for life in the nucleus of all of our cells. Genes were thought to be immutable, fixed for life, except for the occasional mutation. Identical twins were thought to be exactly alike because they carried exactly the same set of genes. So your (phenotype), physical size, skin color, eye color, basic physical structure, susceptibility to various diseases etc. are determined by your genetic make-up (genotype), and this wasn’t thought to change. It was clear, however, that there were other influences on the development of a person. Even identical twins with the same genetic makeup (nature), particularly those raised separately, developed some differences in their characteristics, such as intelligence, athletic ability, health, preferences and accomplishments depending on influences from their environment (nurture).

It was recognized as far back as Aristotle that parents contributed “messages” that led to the formation of a new child. This was a big step from the earliest theories that the male contributes a tiny miniature person to the female who in turn nurtures it in her body until the time of birth. The state of knowledge about inheritance remained pretty much the same until the mid-1800s and the observations and experiments of Darwin and Mendel. The work of these two men began almost a century of observations and experiments to try to determine what accounted for the formation of new life and inheritance. It wasn’t 1944 until that DNA was recognized, through a series of imaginative and exhaustive studies, as the substance that carries the genetic code and that structurally similar RNA reads the DNA genetic template and carries the message from the nucleus to the mitochondria in the cells which in turn manufactures proteins that implement the structures and functions of the body.   What has followed is a deep understanding of the structure of DNA, how genes are arrayed on the various chromosomes and how it carries out its functions. We have also learned the effects of genes, far from being static, can be amplified, diminished, activated or turned off that this is the primary mechanism mediating changes in the body’s health and functioning throughout our life time from fetus to old age.

Humans have somewhere in the neighborhood of a billion genes. The numbers which are active at any point in time are a few thousand. In other words we have many sites on the genome that seemingly aren’t doing anything. A discovery of the last decade is that many of these seemingly blank spots are actually switches that turn on and off other genes largely as a result of challenges encountered from the environment. These are called epigenes. So we have many more genes than those that are active at any point in time. In fact, we have vast warehouses of inactive genes that can respond to new or different challenges. We don’t know what all of them are doing, but it has become clear that many of the functional changes that occur during our life times are mediated through epigenes switching on and off the genes that control functions. One example of a functional change that is turning out to be related to changes in gene function is the development of cancers. We have come to understand that many kinds of cancer (perhaps all) are related to genetic functional changes probably through the activation of genes that previously were silent. The development of the body’s many different kinds of cells (liver, blood, heart, etc.) is probably related to which genes have been activated. Since all cells of an individual have the identical gene complement at birth, something has to instruct the cell to become a liver cell or a blood cell, and this is likely to be mediated through epigene activation of the appropriate structures as the embryo develops.

There are many diseases that appear to have a genetic basis. Some genetic diseases show up at birth.   In these cases, if you have the causative genes in your cells, the disease develops soon after birth. The metabolic defects that cause sickle cells, cystic fibrosis and inherited immunodeficiency are present and manifest from the beginning. However, there are no apparent problems at birth for those who carry genes for type 1 diabetes (onset usually in childhood), schizophrenia (late adolescence), manic-depressive disorder (adulthood), depression or Parkinson’s disease (late life}. The gene or genes have been present from birth, but they apparently don’t have an effect until they are “turned on”. In some instances, as with the case with cancers, environmental factors interact with genes or epigenes to act as triggers for activation. So the exposure to chemicals, smoking, radiation, stress, nutrition and some habits may be, at least in part, mediated through the activation of genes by epigenes, rather than mutation. One can see how the effects of diet, exercise and a variety of other environmental factors can be mediated through activation or inactivation of genes. What this says is that genetic makeup is much more plastic than we imagined when genes were thought to be immutable, and it opens the door to therapy based on blocking or activating genes.

Genetic research has accelerated. Scientists are discovering ways of identifying specific gene abnormalities and of plucking out disease related genes and replacing them with normal versions. Cancer may turn out to be a genetic disease with a cure that can be achieved by manipulating the genetic code. It is also possible to generate stem cells, cells that are undifferentiated and can transform into anything (heart, liver, kidney, etc.). The hope is that it will be possible to infuse these cells and have them replace damaged or lost functions, like dopamine producing neurons in Parkinson’s Disease or heart cells in someone who has had a heart attack. We are still a long way from being able to turn these theories into active therapies, but it is an area where it seems there are almost an infinite number of possibilities.

For those who want to go from this cursory summary to a more detailed understanding, an excellent book written for the lay public is “The Gene, an Intimate History” by Siddhartha Mukherjee.

Reducing the cost of Care

Two months ago, I summarizing the main drivers of the health care costs in the United States, which make health progressively less affordable. I promised to write a subsequent post with some suggested changes to reduce costs or, at least, slow the rate of health care inflation. This is an enormously complicated and arcane subject about which volumes have been written, so my “solutions” will necessarily be simplified. My goal is to give the reader a sense of what might be necessary to slow the runaway costs that now consume 17.5 percent of our GDP.

History:   To briefly set the stage, it is important to understand the traditions of medical practice. Until the early 1940s, medical care was delivered overwhelmingly by solo practitioners or small groups of two and three physicians. There was no health insurance to speak of, and the government programs of Medicare and Medicaid didn’t exist. The technology of medicine was very limited and was largely what a doctor could do in his or her office. Doctors were closely tied to a community, and payment was negotiated between the doctor and patient, largely through the exchange of cash or “in-kind” services. There were few insurance payments, group practices, few specialists, and hospitals were largely for dying patients. The good things about this model were the strong personal relationship between doctor and patient and also doctor’s freedom to determine how he wanted to run his practice. It is what many seniors remember about the good old days of personalized attention from the family doctor.

The disadvantages were that there were no limits to physician hours, no oversight of quality, and no ability to scale up to the advanced technologic world of medical and hospital care. The entry of insurance into both the private and government worlds brought more reliable payment but also greater complexity and administrative costs to doctors’ offices. While physicians complained about the changes in medical practice, they began to slowly gravitate toward larger group practices often with others of the same specialty and sometimes in very large multispecialty practices. The other segments of the health delivery industry also had to scale up. Hospitals began to supply more than nursing care; they have become purveyors of vast technologic resources, sites of highly specialized care, and, in many instances, became owners of physician practices. The pharmaceutical industry had dramatically expanded with an array of drugs that were unimaginable in 1940. And so on with the rest of the health care establishment, the surgical centers, the device manufactures, the nursing care providers, the laboratories, the insurance industry, etc..

One of the problems with this growth is that it has been in silos, each segment independent of the others, each jealously guarding its prerogatives and income. It has resulted in inefficient practices, duplication of effort, incentives to do more or sell more even if it has no benefit to patients’ survival or well-being. I believe that most people in health care are ethical and well motivated, but they are imbedded in separate systems that have no incentives to organize, to be efficient, to do only what is proven by evidence to provide benefit or to be guardians of limited resources.


Absence of an organized system of care: It is difficult to contemplate solving other problems without solving this first. Integrating doctors practices into a system that includes hospital care, diagnostic testing, pharmaceuticals and the various types of needed ancillary care is, I think, the path is to develop systems that are not competing for the patient’s dollar and have incentives to work together to find efficiencies. The oldest, but not the only, integrated care system of care is Kaiser Permanente health system. The Kaiser Permanente Foundation owns the facilities within which the doctors practice. They control the hospitals, the technology, the insurance products, the information systems and most of the back-office administration. They negotiate a contract for services with Permanente Medical Group, the doctors who deliver the care. The two entities work closely together. Customers pay Kaiser a specified each month, and Kaiser must provide all of the needed services for that fee (prepayment). Freed from fee-for-service, they can plan their services any way that they deem most advantageous to the patient and the institution. They are a system of care that can design strategies to avoid overlapping and unnecessary services. For example, they can utilize nurse practitioners and other ancillary personal to perform tasks for which they are qualified without worrying about whether they will be denied payment. Kaiser physicians are paid a salary competitive with what they could earn in their own office, so that there is no reason to churn out extra visits to generate more income. Patient education is encouraged to avoid unnecessary illness and hospitalization.

Other medical groups are organized differently. There are administrative entities that contract with many medical groups in many different locations, giving doctors more freedom to design their practice. However, they generally share an information system and are still held to standards for quality and service. The Sutter Health System in California operates in this fashion. Whatever the mechanism, the goal is to assemble all of the resources (hospital, laboratory, radiologic, outpatient care) under one financial roof to encourage sharing of information and to design more efficient processes.

Most young doctors finishing their training are not interested in opening an office on their own. They desire a more reasonable life style, readily available resources, the stimulation of colleagues to and be freed from administrative hassles. The trend is obvious. Most medical care is going to be provided large entities, which, at least in theory, can deliver comprehensive, efficient care of high quality. There is a cost to this. Care will be far less personalized and will require the patient to learn how to work within what can be a bureaucratic system.

 The current system incentivizes overuse:  I have already written about the perverse incentives of the fee-for-service system.  It encourages churning, the overuse of procedures, and it stifles innovation.  Doctors have little incentive to spend time developing new streamlined methods, which may reduce the number of visits and services if they are being paid fee-for-service. That could, in fact, reduce their income.

Medicare is experimenting with the creation of Accountable Care Organizations (ACOs), entities made up of groups of physicians and hospitals that are responsible for providing all needed care for a for a fixed monthly payment. These are HMOs by another name, but with the difference that patients can choose any physician in the insurer’s network and that there are strict quality controls on the care delivered. HMOs in the 1990s got a bad reputation because of overly restrictive limitations on physician networks and, in some instances, skimping on care. The downside to prepayment is that it reverses the incentives, potentially incentivizing underuse. Quality and satisfaction must be closely monitored.

Expansion of the use of technology: The technologies that have been introduced in the last 50 to 60 years are truly amazing. Technology companies have been booming, and it is clear that there is a lot more to come. In some instances, new technology can save resources, for example doing a CT or MRI scan of the abdomen rather than exploratory surgery. The difficulty is the temptation to overuse these wonderful, but very expensive technologies rather than older but reliable technologies combined with clinical judgment and the passage of time.   In many instances, the new technology is used before it is proven to be better. New products should be studied to show when they are clinically effective and cost effective. Currently insurers have the unenviable task of deciding when a new technology is ready for prime time and should be covered.

Patient demand for services: As I noted in my earlier post, this factor is often cited as a cause of the riding cost of health care. It is unclear to me how much of the rising costs can be attributed to this. Because the payment for service is usually done by an insurer (private or government), out of sight of the patient, it is easy for some to abuse the system and demand excessive services. There is some evidence from a study from the Rand Corporation many years ago that people who had zero financial responsibility for their medical bills used services more readily than those who pay a co-payment and have a deductible. This seems less relevant now when most policies are sold with substantial patient co-pays as employers offload costs to their employees through greater co-payments and deductibles.

Patients’ demands can be increased by the introduction of marketing and advertising.  The pharmaceutical companies in particular have perfected so called “direct to consumer” advertising. There was a time when pharmaceutical companies were prohibited from advertising drugs on public media. That restriction no longer exists, and pharmaceutical companies spend untold amounts touting the benefits of their product on television.

I won’t discuss aging of the population, but it is very real and only going to accelerate in the future. We have visions of life spans getting to be 90 to 100 for the Millennials rather than 70 to 80 as it is now. We have dreams of curing cancer and developing custom drugs and therapies for each patient. That could make health care an impossible burden to carry unless we can figure out ways of making a more efficient and cost-effective system.