I was 25 when I flew home for my father’s last birthday. His cancer had returned and he would die three months later at the age of 57. What I remember most about that weekend was the large rectangular gift box he opened. My mother had bought him a new suitcase.
Credit Getty Images
I don’t know if that suitcase qualifies my family for the Denial Hall of Fame. There are so many contenders for that honor. But I’ve carried the psychic baggage over the years. I have never forgotten that image and how we lost a chance to say goodbye. I still wonder if my father was lonely in the silence that surrounded our inability to talk about what we all knew.
Decades later my mother began a long slow decline. By then, I was a newspaper columnist, a job that I often described as “telling people what you think.” I was professionally outspoken. But little had changed since my father’s death.
Yes, my mother and I talked about everything — but we didn’t talk about how she wanted to live toward the end. The closest we ever came to discussing her wishes was when she would see someone in dire straits and say, “If I’m ever like that, pull the plug.” But most of the time there is no plug to pull.
Gradually and painfully, my mother lost what the doctors call “executive function,” as if she were a C.E.O. fumbling with Excel spreadsheets, not a 92-year-old who couldn’t turn on the television or make a phone call. Eventually, she couldn’t decide what she wanted for lunch, let alone for medical care.
In some recess of my mind, I still assumed that death came in the way we used to think of as “natural.” I thought that doctors were the ones who would tell us what needed to be done. I was strangely unprepared, blindsided by the cascading number of decisions that fell to me in her last years.
I had to say no to one procedure and yes to another, no to the bone marrow test, yes and yes again to antibiotics. How often I wished I could hear her voice in my ear telling me what she wanted. And what she didn’t want.
When my mother died from heart failure and dementia, I began to talk with others. It was extraordinary. Everyone seemed to have a piercing memory of a good death or a hard death. Some of these stories had been kept below the surface for decades, and yet were as deep and vivid as if they’d just happened.
Too many people we love had not died in the way they would choose. Too many survivors were left feeling depressed, guilty, uncertain whether they’d done the right thing.
The difference between a good death and a hard death often seemed to hinge essentially on whether someone’s wishes were expressed and respected. Whether they’d had a conversation about how they wanted to live toward the end.
So, a small group of us — each with his or her own story — started the Conversation Project, a nonprofit, out of the belief that surely we could make this easier. Our partners at the Institute for Healthcare Improvement gathered experts frustrated at the pace of change who believed that the health care system wouldn’t change until the culture changed. So we are trying to change the culture.
There is now, finally, a real momentum for improving end-of-life care. The signs range from the Institute of Medicine’s report, “Dying in America,” to the success of Atul Gawande’s book “Being Mortal.”
There is also a growing public awareness of the need to break through the reluctance that has kept us tongue-tied for so long. A survey we did last year showed that 90 percent of Americans now think it’s important to have the conversation. But the same survey showed something else: Only 30 percent of us have actually had these conversations. So the gap remains huge.
We still need to transform the cultural norm from not talking about how we want to live at the end of life to talking about it. The real work to close the gap is not just for doctors and patients. It’s for mothers and daughters, husbands and wives, families and friends. We have to bring people to the kitchen table to talk with those they love to have the conversation. And to do this before there is a crisis. Not in the I.C.U.
In our survey, the primary reason people gave for not talking to their loved ones was “It’s too soon.” But it’s always too soon … until it’s too late. Half of all elderly people in hospitals cannot make decisions for themselves at the end of life. Far too many health care providers are uncomfortable and untrained in these conversations.
From all the stories shared with us, we know that what people need most is help getting started. They need a travel guide to take the first steps down an unfamiliar and difficult road. So we created a Conversation Starter Kit, which deliberately avoids being a technical medical checklist for the dying in favor of a careful discussion guide for the living.
Our starter kit asks what matters to you, not what’s the matter with you. It asks what’s most important to you in the last phase of your life? Who do you want to make decisions for you? Where do you want to be? Do you worry that you won’t get enough care? Do you worry that you’ll get overly aggressive care?
About two-thirds of the nearly 300,000 people who have come to our website download the starter kit, which is free. We’ve been told repeatedly that conversations that had loomed as frightening and overwhelming repeatedly turned into the most intimate and rewarding moments.
Is it important to have the health care system ready to respect and record our wishes, to have health care providers become more comfortable beginning these talks? Of course. But the hard truth is that we have to begin ourselves — by thinking about our own values, by sharing them, by bringing our own beliefs into the center of the room when decisions will be made.
In my own adulthood, the culture of birth changed. It wasn’t doctors who first tossed out the stirrups and ushered in fathers and video cameras and “birthing rooms.” It was parents who said, birth is not just a medical experience, it’s a human experience. Now we are finally saying that dying, too, is not just a medical experience, it is also a deeply human experience.
Last winter we held a national dinner party to break bread and taboos, to eat comfort food and talk about dying. I shared the table with Nancy Frates, who is known for starting the A.L.S. ice bucket challenge to honor her son Pete. “Now I understand,” she told me. “The conversation is a gift to your family.”
When I helped found the Conversation Project, I thought we were doing this for people who were dying. I thought of my parents. I thought of “executive function” and “baggage.” What I have learned is that the conversation is also a legacy. This is the gift, maybe the last gift, we can give one another.
Ellen Goodman, formerly a syndicated columnist for The Boston Globe, is a founder of the Conversation Project.
One cold March day, when she was 84 and suffering from congestive heart failure, my beautiful mother went to the garage and measured her Camry’s tailpipe, planning to buy a hose to fit it. She was grieving my father’s recent death, living alone in Connecticut with occasional visits from her three grown children in California, and suffering too much chest pain and breathlessness to weed her beloved garden. “There is a possibility for a timely escape,” she wrote in the journal I discovered after her death. “And I will take it.”
She is hardly the first person to yearn to hurry death. The medieval text “Ars Moriendi” (The Art of Dying) called it “the sin of impatience.” But times have changed. As Medicare’s announcement last week of plans to reimburse doctors for end-of-life discussions shows, a once hidden conversation about medical autonomy and the downsides of life-support technologies is exploding into the wider culture. In five states, medical aid in dying is now legal, and bills permitting it have been introduced in legislatures in more than half of the other states. As with same-sex marriage and marijuana, the question may be not whether the laws will change, but when.
I support freedom of choice. But after shepherding my parents through their last years, I doubt that legalizing aid in dying alone will end the current epidemic of unnecessary deathbed suffering.
The way the medical system handles death is broken, and requires bigger fixes than freedom of consumer choice. Many of us will face quandaries far too nuanced to be solved by aid-in-dying laws. My parents certainly did.
At the age of 79, my father suffered a devastating stroke. A year later, he was hurriedly given a pacemaker, which prolonged his worst years while doing nothing to prevent his slide into dementia and misery. When he was unable to remember the names of all his children, my mother and I tried, without success, to get his device painlessly deactivated. It was heart-rending, but in harmony with our values. My father was a stoic. While still mentally competent, he would not have chosen to end his life. But he believed in letting nature take its course. My mother and I, likewise, wanted nature to take my father from us, not an act of his or our own hands.
Today, a slow, bumpy path to the grave like my father’s is common. About seven out of 10 of us now live long enough to die from chronic conditions like heart disease, emphysema, dementia, diabetes, cancer and kidney failure.
Many will spend years in a “gray zone” where medical choices aren’t black and white. We will each have to decide when to allow a natural death and when to say yes to yet another medical technology that might fend off death without restoring health: implantable defibrillators, dialysis, feeding tubes, ventilators and the like.
We will need brave, truthful doctors willing to discuss when to stop fighting for maximum longevity and explore, instead, what may matter more to us. Like living independently at home for as long as possible. Like forgoing treatments that are worse than the disease. Like managing pain. Like living a meaningful life despite physical limitations, and dying a good death, surrounded by one’s family.
This is the province of palliative care, currently medicine’s tin-cup specialty. Its doctors integrate curative medicine, symptom management and shared decision making. Their numbers are too small to meet the need and their comparatively thin paychecks are often covered by philanthropies rather than insurance. Adequately paying them requires redirecting how Medicare money is spent.
Medicare currently pays meagerly for palliative care, hospice and home nursing. It provides hospice care only to patients willing to forgo all curative treatments. But it pays oncologists a 4.3 percent markup on drugs they administer, some costing $10,000 a dose and prescribed after a cure has become a pipe dream. It will pay over $100,000 for open-heart surgery on a patient who may be too fragile to survive it.
This helps explain why a quarter of Medicare payments go for treatment in the last year of life, often last-ditch attempts at cure rather than care. But in a positive change, Medicare is currently selecting hospices for a pilot program that will let some patients receive palliative care without requiring them to forgo what are typically considered curative treatments. And Medicare’s new willingness to pay for discussions of end-of-life options is another good step.
Such programs may start to reduce the widely recognized problem of overly aggressive medical treatment, and attendant suffering, near the end of life. Studies have found that about a third of Medicare patients have surgery in their last year of life, and 17 percent die in an intensive care unit or shortly after a stay. Too many families have cursed, in hindsight, the false hopes, unheld conversations and rushed medical decisions that led them there.
And this matters because death is relational. It leaves an emotional legacy. Everything we do affects those we love, including the manner of our dying. Witnessing death in an intensive care unit often leaves family members with depression, anxiety and complicated grief. So does taking one’s life without saying goodbye.
That is why I am deeply glad my mother did not follow through on her intentions that March day — and equally grateful she decided not to put her fragile body through risky heart surgery that might have led her to a nursing home or a death in an intensive care unit. Instead she died naturally the following September, a month after she had a heart attack.
The memory of her last weeks under hospice care continues to enrich my life. She’d been an uber-homemaker: competent, perfectionistic, self-reliant and far more skilled in caring for others than in accepting help. Yet the dependence she’d dreaded released in her a sweetness, acceptance and wisdom that I’d never before known. She had time to say goodbye to me, and to urge me to “cherish” my longtime partner, Brian. “I love him for what he’s done for you,” she said.
In the hour of our deaths, most of us will yearn not to cut short our time but for a “soft technology” of compassion, caring and interpersonal skill. We will want to give someone our last words and final blessings. We will probably hope to have someone we love at our side, to be forgiven for things we regret and to be remembered. To truly die with dignity, we will need good nursing, practical support, pain management and kindness. All should be better reimbursed by Medicare.
Liberalizing aid-in-dying laws need not preclude any of this, but it will not alone supply it. Dying rarely lends itself to workarounds. It is a messy, nuanced, unpredictable, deeply human, labor-intensive ordeal, and for most of us, it will always be so. It may involve suffering and take time. We need to get honest about this, and pay decently for it.
Katy Butler is the author of “Knocking on Heaven’s Door: The Path to a Better Way of Death” and the administrator of the Slow Medicine group on Facebook.
Subject: Fwd: Urgent info and announcement for your seniors at your session
> > Ya Ali Madat team,
> > PLEASE SHarE THIS EMAIL WITH YOUR TEAMS.
> > Just to briefly let you know that there was a building fire last evening
> > around 5 pm, right at the doorstep of Darkhana (Vancouver) and all the occupants of
> > that building as well as the adjoining building were evacuated.
> > There are about 17 seniors/Families that were affected.
> > Darkhana Social hall was set up as the emergency centre and lots of the
> > residents of those building were taken there (including non-Ismailis).
> > Some of the ISC team members from Darkhana as well as IVC and our own EMT
> > team members were there to support the seniors and all individuals and by
> > 1.00 am this morning everyone of the seniors were placed with friends
> > and/or family.
> > Most of these seniors are on multiple medications (and most of them dont
> > know what they are on) and they had none on them. Thankfully due to our own
> > Ismaili Pharmacist next door, and the centralized system, she was able to
> > supply them all with what they needed.
> > The team worked amazingly well with each other and it was good to see our
> > own team work so well with the distressed seniors.
> > Although the short term solution was provided, to the victims but as you
> > know its hard for them and their families now to struggle to go through the
> > legal / financial and logistic hoops as well as re-adjust to their new
> > surrounding (whilst they wait for whatever repairs etc) and so they are
> > distressed for sure. With Khushiali coming up it is more stressful as their
> > mind is all over the place now:(
> > Please be there to support anyone of them.
> > One thing I noticed is NONE of them had a "GRAB AND GO" kit and we need to
> > emphasize that everyone should have one.
> > They were in shock and disoriented and could not remember the phone #s of
> > their family etc. It took them a long time to react to the significance at
> > what had happened:(
> > We should encourage and help all our seniors to "be prepared" for any sort
> > of disaster.
> > CHECK AND SHARE THIS WEBSITE;
> > http://vancouver.ca/files/cov/safety_kit_handout.pdf
> > *PLEASE ANNOUNCE THE FOLLOWING AT YOUR SESSION AS WELL AS YOUR CLASSES:*
> > *DO YOU HAVE A GRAB AND GO KIT?*
> > *IN CASE OF AN EMERGENCY, YOU SHOULD ALWAYS HAVE A SMALL GRAB AND GO KIT
> > THAT SHOULD BE PLACED NEAR YOUR ENTRANCE AREA SO IT IS EASILY ACCESSIBLE
> > AND YOU CAN TAKE IT WITH YOU WHEN EVACUATING.*
> > *IT CAN BE A SMALL BAG THAT IS EASY TO CARRY.*
> > *SOME OF THE ESSENTIAL ITEMS FOR SENIORS ARE:*
> > *LIST OF PRESCRIBED MEDICATIONS*
> > *EXTRA PRESCRIBED MEDICATIONS*
> > *IMPORTANT DOCUMENTS - OR PHOTOCOPY OF YOUR*
> > *SOCIAL INS #*
> > *PASSPORT*
> > *INSURANCE PAPERS/ CONTACT INFO*
> > *LIST OF NAMES AND PHONE #S OF YOUR FAMILY /FRIENDS*
> > *EXTRA PAIR OF YOUR EYE GLASSES*
> > *EXTRA CAR KEYS/ HOME KEYS*
> > *ONE CHANGE OF CLOTHES*
> > *EXTRA SOFT FOOT WEAR*
> > *1-2 BOTTLE OF WATER*
> > *TOILET PAPER*
> > *FLASHLIGHT*
> > *SOME DRY FOOD AND NUTS*
> > *Thanks so much, *
> > *Regards*
> > *Almas*
These words are often spoken by a physician just before transitioning a patient to hospice and palliative care and are regrettably uttered only days, if not hours, before the person dies. These words leave no room for hope; they make a transition to comfort care a much-feared and often avoided final destination.
Yet here’s the reality: More can always be done. More important, patients know exactly the “more” that they want. The real question is: Why don’t we ask?
“If I had a magic wand, what is it you would wish for today?” This is a question I ask of my patients receiving hospice and palliative care.
No one has ever asked that I rid them of their disease. Rather, I have been met with immediate replies of “make my anxiety go away” or “let me travel to see my family” and “let me go home and sit in my garden.”
These are the things that people say, over and over again, when they are given the opportunity to answer. The real test for physicians, then, is being willing to meet the challenge of discovering our patient’s true wishes, the fulfillment of which may push us well outside our own professional comfort zone.
Sometimes, it is actually the medical team’s best-intended professional wisdom that stands in the way of having patients’ wishes fulfilled. The patient who taught me that, whom I’ll call Ms. Weatherby, was a remarkable 57-year-old with a horrible collection of diseases, which had conspired to stop her lungs from working.
When I first met her she was already on a ventilator, a breathing machine in the intensive care unit, keeping her alive. The sedation required for such life support measures to be tolerable renders most people essentially unconscious. Not so for Ms. Weatherby. She was sitting upright in her bed, tubes entering and exiting nearly every orifice, yet she found ways to position her laptop and journals and myriad colorful pens so that she could be in constant communication with her extensive circle of family and friends.
She was keenly aware that she was not going to make it out of the hospital alive. But she was equally aware that her splintered family was not ready just yet to lose her.
“I want my family to know I am at peace,” she wrote on one of her note pads in response to my magic wand question.
Physicians mostly assume that life support is such an uncomfortable level of medical intervention that no one would ever choose it if they knew no chance for recovery existed and certain death in the hospital would be their only future. Ms. Weatherby challenged that, not in that she thought she would leave the hospital or even the I.C.U. — she knew she wouldn’t. But she defied everyone’s assumptions that life would be too unpleasant and painful in such a setting to be worth living at all. She radiated gratitude.
For several days, Ms. Weatherby had been complaining of increasing abdominal discomfort. She was receiving nutrition via a tube running from her nose into her stomach so had not been able to taste food in days. When I stopped in to see her she grabbed a pen and journal and wrote, “I vomited head to toe last night.” This has to be one of the worst events to happen to someone alert on a ventilator as you have no ability to activate your own gag reflex with a tube stuck down your throat. But she continued to write, undaunted, “My stomach feels much better.” She patted her stomach and kept writing. “After they gave me a bed bath, changed my sheets and clothes, I got to brush my teeth!” Just then she looked like the Cheshire cat showing off her pearly whites. It was the first time anyone had thought to try to let her do it since she had been intubated. “It feels so good. I am looking forward to doing it again tonight!” I said with a laugh, “Yeah, but this time without the vomiting, O.K.?”
Astonishingly, Ms. Weatherby was able to be taken off the ventilator only a couple of days later, placing her in a rare position to answer questions about her care.
“If your lungs weaken again, would you want the tube put back down your throat and be placed back on the breathing machine?” “If that’s what it takes to keep me alive, so be it. I am not ready to pull the plug yet if I don’t have to.” Knowing her as I did, I would have been shocked if she had given any other response. I quickly came to learn that other physicians did not hold that same perspective.
“I’m sorry? You’re telling me she wants to be re-intubated?” Ms. Weatherby’s attending physician exclaimed. “I’m not clear how this is palliative care? She’s never leaving the hospital.”
When advanced life support becomes comfort care, where do we draw the line? Based upon what I learned from Ms. Weatherby, I would argue that palliative care begins by removing the line.
When I returned to Ms. Weatherby’s bedside the following morning, she was re-intubated, alert and tapping away on her laptop. She immediately reached for a notebook and a magenta pen and, as if reading my mind, wrote, “I still want to live.” I said, “I know you do.”
I asked if I could do anything for her. She shrugged, then paused; placing her palms together she bowed her head. “Pray for you?” I whispered. She nodded. “I can do that.”
We both smiled. She straightened her gown and I noticed her bare feet bumping up against the edge of the I.C.U. bed, her flimsy blanket not able to reach so low and maintain modesty above.
“And how about some colorful cozy socks to match your glow?” She nodded emphatically with joy in her eyes. Simple pleasures and abundant gratitude … that was Ms. Weatherby’s way.
She continued to work relentlessly to bring her fractured family back together. Specifically, Ms. Weatherby wanted to ensure that her own death would unite and heal all those she so deeply loved.
Perhaps what makes medicine a frontier of endless discovery has less to do with the scientific advances pushing the envelope on our medical know-how and more to do with how our patients challenge what we believe we know. A week later, Ms. Weatherby’s heart, lungs and kidneys stopped working. Much of her family had been able to travel to see her in person; others visited via Skype.
She died as she had lived, living each moment to the fullest, grateful for what she had been given. Perhaps the choice between continuing “curative” treatment with no hope of cure and reorienting care to fulfilling hopes of what makes life worth living is no more complex than simply asking people to make a wish.
For some, like my father, it may mean being surrounded by the comforting sounds of home like his cat’s purr, the whir of hummingbird wings outside the window and his wife’s snore as she sleeps by his side. And for others, it may mean being left on a ventilator so they can finish saying their goodbyes, knowing then that they may rest in peace.
The only time doctors are left with “nothing more we can do” is when we fail to ask.
Dawn M. Gross, a hospice and palliative care physician who lives in San Francisco, is at work on a book about end-of-life care.
What is the “right” way to die? We’re experiencing a zeitgeist moment about that. “Being Mortal: Medicine and What Matters in the End,” by Atul Gawande, is a best-selling book. Videos by Brittany Maynard, a 29-year-old who wanted to die in a way of her own choosing, went viral last year. And in more than 20 countries, thousands of people have dined and discussed dying through a project called “Death Over Dinner.”
In fact, we can’t afford not to have this conversation. According to the National Institute of Health, 5 percent of the most seriously ill Americans account for more than 50 percent of health care spending, with most costs incurred in the last year of life in hospital settings. Economists call this a “cure at all cost” attitude. And in the next 25 years, longer life spans and the aging of baby boomers are expected to double the number of Americans 65 years or older, to about 72 million.
What if the most promising way to fix the system is to actually do less for the dying?
That’s what the not-for-profit Zen Hospice Project has been trying to prove through a fascinating, small-scale experiment in San Francisco’s Hayes Valley neighborhood.
WE talk a lot these days about what constitutes a good way to die. There’s also much discussion about the art of healthy aging.
But largely absent from the conversation are all the people between the two. People who aren’t dying but who grow more frail. People who have significant health concerns. People who suddenly find themselves in need of care.
People who are, by and large, miserable.
We have a name for this part of life in our family. We call it “the land of pink bibs.”
In his 70s, my father, a highly respected orthopedic surgeon, developed Alzheimer’s. Later in the course of the disease, he broke his hip. One day when we visited him at the nursing center, about six months after his accident, we found him sitting in a row of patients all wearing pink bibs, left on after they had finished eating. Like the others, his head was bent toward his lap; though his eyes were open, they were not focused on anything. His shoulders slouched, like a rag doll’s, and his mouth hung slightly ajar.
We were not prepared to see him like this.
“Oh, not a stroke,” the nurse said. “He is fine. He’s just on a new drug — a mood stabilizer. He was becoming violent to the aides. Patients often get like this when they have Alzheimer’s.”
We were suddenly confronted with decisions about his care that we didn’t understand. Many families face similar questions: Do we move Mom out of her house to assisted living? Dad is so forgetful and argumentative, does he have dementia? Do our parents have enough money to hire a caregiver — and do we? When should we move them to a nursing home? What kind of care will they need when they get there?
These are difficult questions. Yet when you look around for help, you find there isn’t much to be had.
Why not? Most health care professionals have had little to no training in the care of older adults. Currently, 97 percent of all medical students in the United States do not take a single course in geriatrics.
Recent studies show that good geriatric care can make an enormous difference. Older adults whose health is monitored by a geriatrician enjoy more years of independent living, greater social and physical functioning and lower presence of disease. In addition, these patients show increased satisfaction, spend less time in the hospital, exhibit markedly decreased rates of depression and spend less time in nursing homes.
Our family witnessed the value of geriatric care firsthand.
After seeing my father slumped in his chair, we reached out to a leading geriatrician and researcher, Dr. Kenneth Brummel-Smith of Florida State University. After listening to me recount my father’s health history (his broken hip and significant arthritis), Dr. Brummel-Smith suggested that the cause of his behavior might have been pain. The doctor explained that, of all the suffering that goes with dementia, pain is one of the most common and least recognized, simply because patients can’t express themselves.
Dr. Brummel-Smith urged me to have my dad examined by a local geriatrician, whom he recommended. In a week, the new doctor came to the nursing home. Dr. Brummel-Smith’s suspicions had been right. Despite my father’s broken hip and history of arthritis, he was receiving nothing for pain. Immediately, the geriatrician put my father on a regimen of 1,000 milligrams of Tylenol, three times a day. He discontinued the mood-altering drug. After that, my father’s behavior rapidly turned around. His quality of life vastly improved. He could look around at his surroundings. He could converse. He could smile when we played music for him.
My parents were fortunate to have gone into a nursing home where their primary care Internal Medicine physician and her partner followed...
But, as relieved as I felt, I could not help wondering: What about all the other people in nursing homes who aren’t as fortunate as my father?
Currently there are fewer than 8,000 geriatricians in practice nationwide — and that number is shrinking. “We are an endangered species,” said Dr. Rosanne Leipzig, a geriatrician at Mt. Sinai Medical Center in New York.
At the same time, the nation’s fastest-growing age group is over 65. Government projections hold that in 2050 there will be 90 million Americans 65 and older, and 19 million people over age 85. The American Geriatrics Society argues that, ideally, the United States should have one geriatrician for every 300 aging people. But with the looming shortage of geriatricians, the society projects that by 2030 there will be only one geriatrician for every 3,798 older adults.
Why such a growing gap between an increasing number of patients and a decreasing number of doctors required to treat them? Geriatrics is a low-paying field of medicine, even though it requires years of intensive specialization. Most geriatricians are reimbursed solely by Medicare and Medicaid, whose rates make it unsustainable to keep an office running. Many medical clinics and geriatric hospital units nationwide are closing down.
For those entering their senior years, according to Dr. David Reuben, a leading geriatrician at the U.C.L.A. Medical Center, a true national crisis is brewing.
A vast majority of Americans have no conception of what lies ahead and — without geriatricians available to provide their health care — how substantially their lives will be affected.
I know. It means that soon we may all soon be in the land of the pink bibs.
Not long ago, my endocrinologist announced: “You’re healthy. Take care of yourself and there’s no reason you won’t live for decades.”
“What are you talking about?!” I answered. The poor guy was puzzled by my reaction to his cheery news. But I found it disorienting, unnerving.
I was given a diagnosis of insulin-dependent diabetes 53 years ago, at age 7, and this was the first doctor who had ever expressed optimism about my life expectancy. When I was a kid, the conventional wisdom was that my life would probably be cut very short by terrible complications — failed kidneys, nerve damage, cardiovascular carnage. A few months after the diagnosis, I overheard an anxious older cousin murmur that I would be lucky to make it past 35. The terrible complications never came, but my mind-set has long been: Anything after age 35 is borrowed time.
Now that my doctor has semiofficially rewritten my life script, I am off-kilter. How in the world am I going to get through all the extra time that remains?
I’m not the only one with this happy but unsettling problem. The Joslin Diabetes Center has awarded medals to nearly 5,000 diabetics who survived for at least 50 years, including me. We have a private Facebook page. Sometimes my fellow codgers express astonishment that they are still here, thanks to their diligent management of the disease, genetic luck and medical advances like improved insulin formulations, insulin pumps and blood-glucose monitoring technology. Medical progress is allowing people to live for decades with other maladies that used to be tickets to an early grave, like H.I.V./AIDS.
In my case, over the years, the likelihood of impending death was usually not a conscious obsession; it was more like a background hum, akin to annoying traffic noise outside an apartment building. But it was always there when I decided to stop ignoring it. One consequence was an anxious urgency to get things done. I haven’t achieved more than a tiny fraction of my goals. So part of me is inspired by my doctor’s optimistic announcement, and welcomes the news that there still might be enough time to accomplish something worthwhile.
But there’s another, darker part of me, one that emerged occasionally when the intimations of mortality got a little louder. I’ve been frightened by thyroid cancer, prostate problems, bewildering fatigue and weight loss. I’ve worried about the impact of these maladies on my family, of course, but in a little corner of my mind I’ve also been relieved, thinking, This is it! The big one! It’ll all be over soon, no need to keep trying and failing and trying again.
Now, lurking in that same corner, is resentment that my doctor has deprived me of a good excuse to give up.
That excuse used to apply to life as well as work. Of course one doesn’t need to be a diabetic to suffer from depression. But an ingrained expectation that everything will soon dissolve has provided an extra reason for the chronic, low-ebb sadness that has muffled my experience, and for the too-frequent sense of not being fully alive. I would be surprised if other people who expected sharply shortened life spans didn’t get the same sort of blues.
Nevertheless, my doctor’s prediction has prodded me to shake off a complacent acceptance of that sadness, and do more to embrace and appreciate the world. I’ve been telling myself that since there is a decent chance that I’ll live for many more years, I really need to do a better job at getting through time. Maybe it’s not too late to learn how to be in the here and now, to live mindfully, even have fun.
Astonishingly, I’ve made a little progress lately. A meditation practice that I’m taking seriously has helped me focus more intently on what’s in front of me. The world sometimes seems more vivid, and I’ve even been cheerful while laughing at an inane reality TV show with my daughter, and holding my wife’s hand and walking in the woods, and praying at a new synagogue we’ve recently joined. The improvements are incremental, and I don’t yet have confidence that in 20 or 30 years I will be a different person. But I have some cautious hope.
The prospect of longer life brings other unexpected challenges. For one, I’m confronting the tangible possibility of retirement for the first time. While I’ve put aside money for that purpose and my wife and I have met with financial planners, these were dutiful gestures for the sake of her and our daughter. Their future demanded a kind of automatic tribute, but not mine, as I could never envision myself in a time period that stretched more than a year or so from the present.
Now I need to regroup. I need to pay attention to those actuarial tables with average life expectancies that the financial planners used to trot out, because suddenly they apply.
Adding it all up, I’m glad about my doctor’s prognosis. My wife dreams of retiring in Costa Rica or Cambodia, where it will be possible to live well on our modest retirement savings. So I’ve been deliberately trying to picture myself at 75 or so, striding below squawking toucans in a rain forest or buying vegetables in a market in Siem Reap.
Right now, all I can see, from a great distance, is someone else — a grayish and indistinct figure, a wraith. Perhaps if I keep concentrating on him, and imagining the sights and sounds and smells he is experiencing, eventually he will feel unreservedly happy to be alive, and, with enough practice, he will be certain that he belongs in the world.
Dan Fleshler blogs at The Insulin Chronicles and is working on a memoir about Type 1 diabetes.
Of the many factors that affect the experience of dying, the one that patients and families often have the greatest control over is making decisions that are in the patient’s best interest. I recently participated in research on barriers to quality end-of-life care as part of a study released today in the Journal of Palliative Medicine. Some of the hurdles we identified, such as financial limitations or access to top doctors, may require societal change. But I am focusing here on the personal part of the puzzle that all patients, whatever their socioeconomic status, should have the potential to influence.
Most of us will lose our ability to make medical decisions for ourselves in the last phase of our lives. Patients with illnesses like dementia may lose the ability to make decisions months or even years before they die. Others who die of illnesses like cancer, liver disease and kidney disease may lose the ability to make decisions during the last days of their lives.
As the illness progresses, many struggle with distressing symptoms like severe pain, nausea, air-hunger, confusion and agitation. At this point, most patients just do not have the bandwidth to process complex medical information, weigh the risks and benefits and make choices.
When the patient is unwilling or unable to make medical decisions, the health care proxy is activated and he or she is obligated to make all health choices on behalf of the patient. These may be related to withdrawing or withholding life support, instituting artificial liquid feeding, attempting resuscitation and even whether or not to participate in autopsy and organ donation.
The concept of proxy decision-making assumes that a human being is capable of temporarily suspending personal beliefs and biases, metaphorically entering the head of the patient, and making decisions that the patient would have made under the given circumstances. Processing complex medical information and making high-stakes decisions for another person is always fraught with uncertainty and stress. Proxy decision-makers are often unprepared, and many may not be cognizant of the patient’s values and wishes. Even when the patient has well-documented advance directives, ultimately, the proxy has the power to override these directives.
As part of our research, my lab at Stanford interviewed many patients and patient’s family members on this topic; some of their stories are included in this video.
There are three common traps that the proxy decision-maker should be aware of in trying to make decisions for the patient – many of them life-altering decisions that must be made in a stressful situation with little time to think. In the examples below, patients’ names and details of their cases have been altered to protect their privacy.
The first and most common trap is what I call the Call of Love. Darlene, a patient with advanced lung disease, completed advance directives and the Physicians Order of Life Sustaining Treatment stating clearly that she did not want to be resuscitated if her heart were to stop. A bad pneumonia pushed Darlene into respiratory failure and she lost consciousness and would have died. Her partner, Carl, who could not imagine a life without Darlene, used his proxy status to override her directives. Darlene was resuscitated and stabilized on life support and eventually discharged from the hospital. However, Darlene was terribly upset at Carl for preventing her from dying naturally, which is what would have happened if resuscitation had not been attempted. When Carl argued that his decision to override Darlene was correct as she was “saved,” Darlene angrily responded, “That’s because you think that I want to live this way with this horrible disease. How can I ever trust you again?”
Proxy decision-makers can and do override the patient’s stated wishes. If resuscitation prolongs the patient’s life, the proxy views this as evidence that the right decision was made. While some patients are willing to allow the proxy to override their decisions, most expect the proxy to uphold their wishes.
The second trap to avoid is the Call of Duty. Jong, a Korean-American patient, was dying with metastatic cancer. A cycle of chemotherapy wiped out his immune system; he then succumbed to a vicious bug and was admitted to the intensive care unit for maximal life-support. Jong did not have advance directives and his wife, Soo-jin, was his default proxy decision maker. Despite maximal therapy, Jong’s condition deteriorated and the medical team wanted to withdraw life support and allow him to die.
Soo-jin was a soft-spoken woman who was respectful and deferential to the doctors. However, she categorically refused to entertain any discussions about withdrawal of life support.
One evening, after yet another long and ineffective discussion, I asked the question that had been echoing in my head. Is this what Soo-jin would want for herself, were she in her husband’s shoes? Of course not, she said. She would want to just die peacefully. So why was she subjecting her husband to this fate? “The duty of a good wife is to save her husband,” she said softly and with steely determination. The call of duty is loud and difficult to ignore. Here, the role as a dutiful spouse or parent or sibling obligates the proxy to execute decisions for the patient that the proxy would never stomach for himself or herself.
The final trap to avoid is the Call of Redemption. James was an octogenarian with severe heart failure. He had been hospitalized several times in the past year. Over the holidays, he lost consciousness and his neighbor called 911. He was admitted to the intensive care unit and placed on life support. Despite maximal medical therapy, his blood pressure remained extremely low, his kidneys shut down and he could not be aroused. The social worker tracked down his son, John, who lived in another state. John was busy with his life and had not visited his father for a few years. When he arrived, the I.C.U. team met with him and asked for his permission to withdraw high-intensity treatments to allow his father to die.
As John sat at the bedside of his dying father, all he could remember was the Thanksgiving dinners he had missed, and the phone calls he should have made to his father. Now, arriving to see his father at death’s door, John’s strong instinct was to take on the role of the defender and fight to protect his father from the doctors who wished to withdraw life support. In situations like this, the proxy (knowingly or unknowingly), is primarily motivated by his own need to have one last opportunity to repair the broken relationship and make amends to redeem himself.
As each of us identifies our proxy decision makers, the question we should ask is not just how much they love us but rather, how capable are they of implementing our wishes and preferences? The question each proxy should ask when making decisions on behalf of others is, who am I truly serving - the patient or myself?
For six New Yorkers age 85 and older, whose lives were
followed throughout the year, old age is a mixture of happiness
and sadness, with less time wasted on anger and worry.
Do you know what you want to do when you get old?
Since the start of the year, the photographer Nicole Bengiveno and I have been visiting Mr. Sorensen and five other New Yorkers over the age of 85 — in hospital rooms and at birthday parties, on family vacations and at readings in nightclubs — and through it all, some version of Mr. Sorensen’s question has lingered: What is reasonable to ask of old age? Beyond the assaults of poverty or illness, to what extent can people shape the quality of life in their late years?
In New York City, the population age 85 and up has been growing at five times the rate for the city as a whole, doubling since 1980 to about 150,000. For this often invisible population, the first of its size, what does an older life really look like? And can it be better?
Throughout the year, the six talked unflinchingly about death and loss, but also about love and connection, about accomplishment and meaning. A paradox of old age is that older people have a greater sense of well-being than younger ones — not because they’re unreservedly blissful, but because they accept a mixture of happiness and sadness in their lives, and leverage this mixture when events come their way. They waste less time on anger, stress and worry. As Ping Wong, 90, put it: “When you’re young, the future is so far away, and you don’t know what will happen to you and the world. So when you’re young, you have more worries than the elderly. But I don’t worry now.”
Everyone struggles to come up with a name once in a while. But how can you tell if it's more serious?
"One symptom alone does not necessarily indicate that a person has Alzheimer's or dementia," says Raj C. Shah, MD, of the Rush Memory Clinic at Rush University Medical Center, in Chicago. (Dementia is chronic loss of cognition, usually affecting memory, and Alzheimer’s causes 50% to 80% of dementia cases.)
There are many other causes of memory loss, including vitamin B12 deficiency, and brain, thyroid, kidney, or liver disorders. However, having several other symptoms could be a sign of Alzheimer's disease (AD).Recognizing the signs of dementia can help lead to a quicker diagnosis.
Even if someone has Alzheimer's, it doesn't mean his or her life is over; a person with AD can live a meaningful and productive life for many years, but it's important to get a proper diagnosis.
People often wait too long to seek help, says Dr. Shah.
"Most diagnoses are still made in the moderate stage, after most individuals have been experiencing symptoms for years already," says Dr. Shah. "It doesn't help the person or family to wait until symptoms become so obvious that the diagnosis can be easily made. It is better to seek an evaluation earlier to help maintain quality of life and to prevent social or medical crises due to memory loss."
World’s first anti-ageing drug could see humans live to 120
The world’s first anti-ageing drug will be tested on humans next year in trials which could see diseases like Alzheimer’s and Parkinson’s consigned to distant memory.
Scientists now believe that it is possible to actually stop people growing old as quickly and help them live in good health well into their 110s and 120s.
Although it might seem like science fiction, researchers have already proven that the diabetes drug metformin extends the life of animals, and the Food and Drug Administration in the US has now given the go ahead for a trial to see if the same effects can be replicated in humans.
“This would be the most important medical intervention in the modern era, an ability to slow ageing”
Dr Jay Olshansky, University of Illinois Chicago
If successful it will mean that a person in their 70s would be as biologically healthy as a 50 year old. It could usher in a new era of ‘geroscience’ where doctors would no longer fight individual conditions like cancer, diabetes and dementia, but instead treat the underlying mechanism – ageing.
Scottish ageing expert Professor Gordon Lithgow of the Buck Institute for Research on Ageing in California, is one of the study advisors.
“If you target an ageing process and you slow down ageing then you slow down all the diseases and pathology of ageing as well,” he said “That’s revolutionary. That’s never happened before.
“I have been doing research into ageing for 25 years and the idea that we would be talking about a clinical trial in humans for an anti-ageing drug would have been though inconceivable.
“But there is every reason to believe it’s possible. The future is taking the biology that we’ve now developed and applying it to humans. 20 years ago ageing was a biological mystery. Now we are starting to understand what is going on.”
Dogs Test Drug Aimed at Humans’ Biggest Killer: Age
The drug, rapamycin, which improved heart health and appeared to delay the onset of some diseases in older mice, may not work the same magic in dogs, for another. There is also a chance it could do more harm than good. “This is just to look for side effects, in dogs,” Ms. Gemmell told Bela’s many well-wishers.
Technically that is true. But the trial also represents a new frontier in testing a proposition for improving human health: Rather than only seeking treatments for the individual maladies that come with age, we might do better to target the biology that underlies aging itself.
I can’t promise this will prolong your life. But it will improve it.
"Let me suggest something that might do all of these things — which is to say, might not — but will, as nothing else will, provide you with a deeply satisfying sense of yourself that you did have when you were much, much younger. Find something — something new, something difficult — to immerse yourself in and improve at."
Oslo — EVER since Neil Armstrong walked on the moon, American politicians have promised “moonshots” — huge programs, stocked with technology and experts, to solve presumably intractable problems. A common target is cancer: Earlier this year President Obama announced the National Cancer Moonshot Initiative, a $1 billion program led by Vice President Joseph R. Biden Jr.
But cancer isn’t space travel. The growing cancer epidemic is not a problem that medical science is about to solve. In fact, it is a problem we are about to make worse. The better we get at keeping people alive, the older they will get, and the more cancer there will be in the population. How we deal with this paradox will shape the future of society, and our leaders need to understand why.
Dealing with an aging population is one of the major challenges that the city-state faces as it cements its status as an advanced cosmopolitan nation. Just 50 years after it gained its independence from Malaysia, Singapore has one of the highest per capita rates of gross domestic product in the world, and it boasts world-class systems of education, social housing and health care.
Dealing with an aging population is one of the major challenges that Singapore faces as it cements its status as an advanced nation.
Yet such rapid progress has led to a divergence in lifestyles between the younger generation, brought up in an age of relative security and material comfort, and their grandparents, people of the so-called Pioneer Generation (as the government designates citizens born before 1949). How to care for the elderly has become a major topic of public concern. Singapore is grappling not only with the practical effects of a growing social phenomenon but also with the impact that this has on its identity as a country that straddles modernity and tradition, East and West.
At the heart of the debate is the idea of the Southeast Asian family. Across the three main ethnic groups in Singapore — Chinese, Malay and Indian — one major similarity is the expectation of three generations living under the same roof. Grandparents traditionally live with their children and grandchildren once they have retired. They are expected to contribute to housework and the supervision of the youngest members of the family. In return, they enjoy the emotional and financial support of their families.
“Looking after your parents,” in this still strongly Confucian-influenced society, is a concept most Singaporeans have grown up with. So the notion of parents’ going out to work in a job past the retirement age, particularly in physically demanding, low-paid jobs like the food-hall cleaners’ work, sits uneasily with traditional ideas of filial duty.
The recent news about improving the Canada Pension Plan for tomorrow’s retirees has Harris Gulko feeling a little put out.
“There’s a lot of material being written about what is going to happen to people in the future, and there’s no regard for people who have been retired for 20 or 30 years,” the 88-year-old Winnipeg resident said in an interview.
Mr. Gulko, a writer, painter and former professional fundraiser, is not an angry complainer. He just wants a little understanding for retirees like him who feel they’re being marginalized or forgotten. For reasons related to both demographics and basic personal finance, let’s hear him out.
What bugs him is a sense of being pushed to the margins – overlooked in discussions about improving the CPP and patronized with labels like aged and senior. His message to everyone: Age is just a number.
“I’m an older person,” he said. “That’s a mathematical fact. I’m older – that’s it.”
What can God and nature have had in mind when they designed the aging process? Why is it that just when our mental prowess, our human maturity, and our emotional freedom are at their peak, the body begins to fall apart?
Our faith, of course, because it opens us to a perspective beyond our biological lives, sheds some light on these questions, though it doesn’t always give us a language within which to grasp more reflectively what is happening to us in the aging process. Sometimes a secular perspective can be helpful and that is the case here.
James Hillman, in a brilliant book on aging entitled, The Force of Character and Lasting Life, takes up these questions. What did God and nature have in mind when designing the aging process? He answers with a metaphor: The best wines have to be aged in cracked old barrels. The last years of our lives are meant to mellow the soul and most everything inside our biology conspires together to ensure that this happens. The soul must be properly aged before it leaves. There’s intelligence inside of life, he asserts, that intends aging just as it intends growth in youth. It’s a huge mistake to read the signs of aging as indications of dying rather than as initiations into another way of life. Each physical diminishment (from why we have to get up at night to go to the bathroom to why our skin sags and goes dry) is designed to mature the soul. And they do their work without our consent, relentlessly and ruthlessly.
The aging process, he asserts, eventually turns us all into monks and that, indeed, is its plan, just as it once pumped all those excessive hormones into our bodies to drive us out of our homes at puberty. And God again is in on this conspiracy. Aging isn’t always pleasant or easy; but there’s a rhyme and reason to the process. Aging deliteralizes biology. The soul finally gets to trump the body and it rises to the fore: “We can imagine aging as a transformation in beauty as much as in biology,” writes Hillman. “The old are like images on display that transpose biological life into imagination and art. The old become strikingly memorable, ancestral representations, characters in the play of civilization, each a unique, irreplaceable figure of value. Aging: an art form?”
Increasingly, as we age, our task is not productivity, but reflection, not utility, but character. In Hillman’s words: “Earlier years must focus on getting things done, while later years consider what was done and how.” The former is a function of generativity, we are meant to give our lives away; the latter is a function of dying, we are also meant to give our deaths away.
And the aging process raises a second series of questions: What value do the elderly have once their productive years are over? Indeed the same question might be asked of anyone who cannot be useful and productive in a practical sense: What is the value of someone living with Alzheimer’s? What is the value of people continuing to live on in palliative care when there is no chance of recovery or improvement and they have already slipped away from us mentally? What is the value of the life of a person who so mentally or physically challenged that by normal standards he or she cannot contribute anything?
Again, Hillman’s insights are a valuable supplement to the perspectives offered us through our faith. For Hillman, what aging and disability bring into the world is character. Not just their own. They help give character to the others. Thus, he writes: “Productivity is too narrow a measure of usefulness, disability too cramping a notion of helplessness. An old woman may be helpful simply as a figure valued for her character. Like a stone at the bottom of a riverbed, she may do nothing but stay still and hold her ground, but the river has to take her into account and alter its flow because of her. An older man by his sheer presence plays his part as a character in the drama of the family and neighborhood. He has to be considered, and patterns adjusted simply because he is there. His character brings particular qualities to every scene, adds intricacy and depth by representing the past and the dead. When all the elderly are removed to retirement communities, the river flows smoothly back home. No disruptive rocks. Less character too.”
Aging and disability need to be regarded aesthetically. We are culture that does everything it can to deny, delay, and disguise aging. We put our elders away into separate homes, away from mainstream life, tucked away, no disruptive rocks for us to deal with. We are also a culture that is beginning to talk more and more about euthanasia, defining value purely by utility. If Hillman is right, and he is, than we are paying a high price for this, we have less character and less color.
BLACKPOOL, England — The woman on the other end of the phone spoke lightheartedly of spring and of her 81st birthday the previous week.
“Who did you celebrate with, Beryl?” asked Alison, whose job was to offer a kind ear.
“No one, I…”
And with that, Beryl’s cheer turned to despair.
Her voice began to quaver as she acknowledged that she had been alone at home not just on her birthday, but for days and days. The telephone conversation was the first time she had spoken in more than a week.
About 10,000 similar calls come in weekly to an unassuming office building in this seaside town at the northwest reaches of England, which houses The Silver Line Helpline, a 24-hour call center for older adults seeking to fill a basic need: contact with other people.
Loneliness, which Emily Dickinson described as “the Horror not to be surveyed,” is a quiet devastation. But in Britain, it is increasingly being viewed as something more: a serious public health issue deserving of public funds and national attention.
Working with local governments and the National Health Service, programs aimed at mitigating loneliness have sprung up in dozens of cities and towns. Even fire brigades have been trained to inspect homes not just for fire safety but for signs of social isolation.
“There’s been an explosion of public awareness here, from local authorities to the Department of Health to the media,” said Paul Cann, chief executive of Age UK Oxfordshire and a founder of The Campaign to End Loneliness, a five-year-old group based in London. “Loneliness has to be everybody’s business.”
Researchers have found mounting evidence linking loneliness to physical illness and to functional and cognitive decline. As a predictor of early death, loneliness eclipses obesity.
“The profound effects of loneliness on health and independence are a critical public health problem,” said Dr. Carla M. Perissinotto, a geriatrician at the University of California, San Francisco. “It is no longer medically or ethically acceptable to ignore older adults who feel lonely and marginalized.”
In Britain and the United States, roughly one in three people older than 65 live alone, and in the United States, half of those older than 85 live alone. Studies in both countries show the prevalence of loneliness among people older than 60 ranging from 10 percent to 46 percent.
While the public, private and volunteer sectors in Britain are mobilizing to address loneliness, researchers are deepening their understanding of its biological underpinnings. In a paper published earlier this year in the journal Cell, neuroscientists at the Massachusetts Institute of Technology identified a region of the brain they believe generates feelings of loneliness. The region, known as the dorsal raphe nucleus, or D.R.N., is best known for its link to depression.
It might not seem that Hillary Clinton and Donald J. Trump have much in common. But they share something important with each other and with a whole lot of their fellow citizens. Both are job seekers. And at ages 68 and 70, respectively, they’re part of a large group of Americans who are radically upending the concept of retirement.
In 2016, almost 20 percent of Americans 65 and older are working. Some of them want to; many need to. The demise of traditional pensions means that many people have to keep earning in their 60s and 70s to maintain a decent standard of living.
These older people represent a vast well of productive and creative potential. Veteran workers can bring deep knowledge to the table, as well as well-honed interpersonal skills, better judgment than the less experienced and a more balanced perspective. They embody a natural resource that’s increasing: the social capital of millions of healthy, educated adults.
Why, then, are well over a million and a half Americans over 50, people with decades of life ahead of them, unable to find work? The underlying reason isn’t personal, it’s structural. It’s the result of a network of attitudes and institutional practices that we can no longer ignore.
The problem is ageism — discrimination on the basis of age. A dumb and destructive obsession with youth so extreme that experience has become a liability. In Silicon Valley, engineers are getting Botox and hair transplants before interviews — and these are skilled, educated, white guys in their 20s, so imagine the effect further down the food chain.
First-in-Canada Program Will Save Seniors Money and Support Healthy Aging
Ontario is the first jurisdiction in Canada to provide the shingles vaccine free of charge, saving eligible seniors approximately $170 and helping them stay healthy.
Starting today, the shingles vaccine will be available across the province for people 65 to 70 years of age. The government is investing $68 million over three years in order to publicly fund the vaccine, which will reduce the likelihood of Ontario seniors developing the painful infection, and reduce visits to emergency rooms and hospitals.
Shingles, also known as herpes zoster, affects more than 42,000 people every year in Ontario and can cause complications such as loss of vision and debilitating nerve pain. Studies show that the vaccine is highly effective when seniors are vaccinated between the ages of 65 - 70, and this new program aligns with scientific and expert recommendations from Canada's National Advisory Committee on Immunization and Ontario's Provincial Infectious Diseases Advisory Committee on Immunization.
Those who are eligible for the shingles vaccine should contact their primary care doctor or nurse practitioner to receive the vaccination.
Expanding Ontario's publicly funded immunization program to help seniors stay healthy is part of the government's plan to build a better Ontario through its Patients First: Action Plan for Health Care, which is providing patients with faster access to the right care, better home and community care, the information they need to stay healthy and a health care system that's sustainable for generations to come.
•Approximately 850,000 seniors between the ages of 65 and 70 years will be eligible to receive the publicly funded shingles vaccine.
•During the 2016 year only, any Ontarian who was born in 1945 can receive the vaccine up to December 31, 2016 to ensure that individuals close to the upper age eligibility cut-off have sufficient time to get vaccinated.
•Ontario is the only jurisdiction in Canada to date that is introducing the shingles vaccine as part of its publicly funded immunization program.
•Shingles is caused by the reactivation of the varicella zoster virus, the same virus that causes chickenpox. Shingles creates painful skin rashes with blisters, usually on one side of the body, often in a strip. The best protection from shingles is immunization.
•The most frequent complication of shingles is post-herpetic neuralgia which is prolonged and often debilitating pain.
•Ontario’s health care budget has increased from $47.6 billion in 2012-13 to a total of $51.8 billion in 2016-17.
•This year’s $51.8 billion investment in health care is a 2.1 per cent increase over last year – greater than the rate of inflation.
•Canada’s National Advisory Committee on Immunization
•Ontario’s Provincial Infectious Diseases Advisory Committee
•Patients First: Action Plan for Health Care
Never mind assisted-dying, our health care system needs to change the way it deals with the natural end of life
I’ve spent much of my career in the health care field, but it took a very personal experience to drive home just how poorly prepared health care providers are to help us through the one certain life-experience that awaits us all: death.
It happened in a hospital in southern Ontario. My father-in-law, Ijaz Ahmad, who lived with insulin-dependent diabetes for 35 years, went into the hospital for a partial foot amputation due to a bone infection.
Prior to surgery, a routine diagnostic test was performed requiring dye to be inserted into his bloodstream. After the surgery, the dye put him into kidney failure while it was being metabolized. Within a day of the surgery all of his organs started to fail and he was put on life support for what we were told would be two to three days so his organs could rest and strengthen — after which, we were told, “the doctors would bring him back.”
He spent the next 18 days on life support. And what became clear over that long 18-day ordeal is that what had clearly become the end of his life would have been unnecessarily prolonged depending on which of the eight doctors we interacted with was treating him that day.
Like so many families who have had the difficult but essential conversation with an aging parent around their end-of-life wishes, we had spoken with him about his wishes. He was clear he did not want to be on life support.
People all over the world are living longer due to improvements in lifestyle standards, medications, and better healthcare. The average life expectancy in almost every country has increased over the last several decades. The following ranking, in an ascending order, is based on 2016 CIA estimates. Life expectancy at birth compares the average number of years to be lived by a group of people born in the same year. It is also a measure of overall quality of life in a country.
American scientists have predicted that human life span may be limited to about 115 years. Published in the British science journal, Nature, the researchers studied years of data on human longevity to reach the conclusion.
Thanks to vaccines, better treatment of cancer and heart disease and safer methods of childbirth, there has been an unprecedented increased in life expectancy among humans.
The data reveals a slower expectancy of life among centenarians. According to one of the researchers, Prof. Jan Vijg, “For the first time in history we've been able to see this, it looks like the maximum life span - this ceiling, this barrier - is about 115. It's almost impossible you'll get beyond it, you need 10,000 world's like ours to end up with one individual in a given year who will live until 125 - so a very small chance."
Jeanne Calment (pictured) of France, is on record as the oldest person, at 122 years and 164 days, until she passed away in Aug. 1997.
What’s the Longest Humans Can Live? 115 Years, New Study Says
Dr. Vijg and his graduate students Xiao Dong and Brandon Milholland published the evidence for this pessimistic prediction on Wednesday in the journal Nature. It’s the latest volley in a long-running debate among scientists about whether there’s a natural barrier to the human life span.
Leading figures in the debate greeted the new study with strong — and opposing — reactions.
The Gray Gender Gap: Older Women Are Likelier to Go It Alone
Every few years, a group of federal agencies publishes a raft of data on every conceivable subject affecting older people. Housing. Employment. Leisure.
The numbers that jumped out at me from the latest report, called Older Americans 2016, concerned a more intimate matter: gender differences in marital status. To be blunt, they’re enormous, with consequences beyond the purely personal.
At every age, the report shows, older men are far more likely to be married than older women.
An 80-Year-Old Model Reshapes China’s Views on Aging
BEIJING — Before cranking up the techno music at his 80th birthday party, the man known as “China’s hottest grandpa” paused from his D.J. duties to poke fun at the country’s staid traditional celebrations for the elderly.
“I should wear a long robe, with the word ‘longevity’ embroidered on the front,” the birthday boy, Wang Deshun, said at his party in September.
Far from looking frail, the silver-haired actor, model and artist wore a crisp white shirt and black jeans, his back straight and his eyes glittering with humor.
“Two young maidens should help me into an old-style wooden chair,” he added, pretending to hobble.
Determined to avoid mental and physical stagnation, Mr. Wang has explored new skills and ideas while devoting ample time to daily exercise. Last year, he walked the runway for the first time, his physique causing a national sensation. He takes obvious joy in subverting China’s image of what it means to be old.
And old age in China begins relatively early. The legal retirement age for women is 50 for workers and 55 for civil servants, and 60 for most men.
Being older in China typically means being respected, but also, often, sentimentalized. Someone as young as 50 may be addressed as “yeye” or “nainai” — grandpa or grandma — regardless of whether they have offspring.
Mr. Wang is having none of that.
“One way to tell if you’re old or not is to ask yourself, ‘Do you dare try something you’ve never done before?’ ” he said in a recent interview at a hotel in Beijing.
“Nature determines age, but you determine your state of mind,” he said.
Think about the people in your life who are 65 or older. Some of them are experiencing the usual mental difficulties of old age, like forgetfulness or a dwindling attention span. Yet others somehow manage to remain mentally sharp. My father-in-law, a retired doctor, is 83 and he still edits books and runs several medical websites.
Why do some older people remain mentally nimble while others decline? “Superagers” (a term coined by the neurologist Marsel Mesulam) are those whose memory and attention isn’t merely above average for their age, but is actually on par with healthy, active 25-year-olds. My colleagues and I at Massachusetts General Hospital recently studied superagers to understand what made them tick.
Our lab used functional magnetic resonance imaging to scan and compare the brains of 17 superagers with those of other people of similar age. We succeeded in identifying a set of brain regions that distinguished the two groups. These regions were thinner for regular agers, a result of age-related atrophy, but in superagers they were indistinguishable from those of young adults, seemingly untouched by the ravages of time.
What are these crucial brain regions? If you asked most scientists to guess, they might nominate regions that are thought of as “cognitive” or dedicated to thinking, such as the lateral prefrontal cortex. However, that’s not what we found. Nearly all the action was in “emotional” regions, such as the midcingulate cortex and the anterior insula.
My lab was not surprised by this discovery, because we’ve seen modern neuroscience debunk the notion that there is a distinction between “cognitive” and “emotional” brain regions.
This distinction emerged in the 1940s, when a doctor named Paul MacLean devised a model of the human brain with three layers. An ancient inner layer, inherited from reptiles, was presumed to contain circuits for basic survival. The middle layer, the “limbic system,” supposedly contained emotion circuitry inherited from mammals. And the outermost layer was said to house rational thinking that is uniquely human. Dr. MacLean called this model “the triune brain.”
The triune brain became (and remains) popular in the media, the business world and certain scientific circles. But experts in brain evolution discredited it decades ago. The human brain didn’t evolve like a piece of sedimentary rock, with layers of increasing cognitive sophistication slowly accruing over time. Rather (in the words of the neuroscientist Georg Striedter), brains evolve like companies do: they reorganize as they expand. Brain areas that Dr. MacLean considered emotional, such as the regions of the “limbic system,” are now known to be major hubs for general communication throughout the brain. They’re important for many functions besides emotion, such as language, stress, regulation of internal organs, and even the coordination of the five senses into a cohesive experience.
And now, our research demonstrates that these major hub regions play a meaningful role in superaging. The thicker these regions of cortex are, the better a person’s performance on tests of memory and attention, such as memorizing a list of nouns and recalling it 20 minutes later.
Of course, the big question is: How do you become a superager? Which activities, if any, will increase your chances of remaining mentally sharp into old age? We’re still studying this question, but our best answer at the moment is: work hard at something. Many labs have observed that these critical brain regions increase in activity when people perform difficult tasks, whether the effort is physical or mental. You can therefore help keep these regions thick and healthy through vigorous exercise and bouts of strenuous mental effort. My father-in-law, for example, swims every day and plays tournament bridge.
The road to superaging is difficult, though, because these brain regions have another intriguing property: When they increase in activity, you tend to feel pretty bad — tired, stymied, frustrated. Think about the last time you grappled with a math problem or pushed yourself to your physical limits. Hard work makes you feel bad in the moment. The Marine Corps has a motto that embodies this principle: “Pain is weakness leaving the body.” That is, the discomfort of exertion means you’re building muscle and discipline. Superagers are like Marines: They excel at pushing past the temporary unpleasantness of intense effort. Studies suggest that the result is a more youthful brain that helps maintain a sharper memory and a greater ability to pay attention.
This means that pleasant puzzles like Sudoku are not enough to provide the benefits of superaging. Neither are the popular diversions of various “brain game” websites. You must expend enough effort that you feel some “yuck.” Do it till it hurts, and then a bit more.
In the United States, we are obsessed with happiness. But as people get older, research shows, they cultivate happiness by avoiding unpleasant situations. This is sometimes a good idea, as when you avoid a rude neighbor. But if people consistently sidestep the discomfort of mental effort or physical exertion, this restraint can be detrimental to the brain. All brain tissue gets thinner from disuse. If you don’t use it, you lose it.
So, make a New Year’s resolution to take up a challenging activity. Learn a foreign language. Take an online college course. Master a musical instrument. Work that brain. Make it a year to remember.
Lisa Feldman Barrett, a professor of psychology at Northeastern University, is the author of the forthcoming “How Emotions Are Made: The Secret Life of the Brain.”
Loneliness Can Be Deadly for Elders; Friends Are the Antidote
The circle shrinks. As the years pass, older people attend too many funerals. Friendships that sustained them for decades lapse when companions and confidants retire or move away or grow ill.
These days Sylvia Frank, who moved into an independent living residence in Lower Manhattan in 2014, can email or call one longtime friend in Florida. Another, in Queens, is slipping into dementia and will most likely exclaim, “I haven’t spoken to you in months!” when, in fact, they talked the day before.
But even at advanced ages, new relationships take root. Ms. Frank’s son kept telling her that a colleague’s cousin, Judy Sanderoff, was about to move into the same facility. They sought each other out.
Now, Mrs. Frank, 91, and Ms. Sanderoff, 96, eat breakfast together almost daily; they have dinner, à deux or with other friends, many evenings. Ms. Sanderoff spent Thanksgiving with Ms. Frank’s family in Brooklyn.
Study Says Meditation Could Protect The Brain From Signs Of Aging
Meditation is good for the brain. A new wave of research has connected the ancient practice to many cognitive benefits, from greater attention and focus to reduced symptoms of anxiety and depression to improved cognitive control and executive functioning.
According to a new study from the UCLA Brain Mapping Center, meditation may also protect the aging brain. Researchers from the University of California at Los Angeles and Australian National University found that the brains of longtime meditators were less affected by aging than the brains of those who don’t meditate.
The brain begins to decline in the 20s, and continues to decrease in volume and weight through old age. Meditation, in addition to boosting emotional and physical well-being at any time in life, may be an effective way to prevent neurodegenerative diseases like dementia, Alzheimer’s and Parkinson’s, as well as help stave off some of the normal cognitive decline that comes with aging. The strategy is free, and it comes with no side effects.
As recently as 2000 it was thought impossible that a country’s average life expectancy would ever exceed 90. That so many developed countries can expect people to live beyond 80 is testament to health-care successes. The next challenge for governments will be to ensure there are sufficient health and social care policies in place to support fast-swelling older populations.
In 1946, a 23-year-old Army veteran named John Goodenough headed to the University of Chicago with a dream of studying physics. When he arrived, a professor warned him that he was already too old to succeed in the field.
Recently, Dr. Goodenough recounted that story for me and then laughed uproariously. He ignored the professor’s advice and today, at 94, has just set the tech industry abuzz with his blazing creativity. He and his team at the University of Texas at Austin filed a patent application on a new kind of battery that, if it works as promised, would be so cheap, lightweight and safe that it would revolutionize electric cars and kill off petroleum-fueled vehicles. His announcement has caused a stir, in part, because Dr. Goodenough has done it before. In 1980, at age 57, he coinvented the lithium-ion battery that shrank power into a tiny package.
We tend to assume that creativity wanes with age. But Dr. Goodenough’s story suggests that some people actually become more creative as they grow older. Unfortunately, those late-blooming geniuses have to contend with powerful biases against them.
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