Tag: Elderly

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disability Emotion Lifestyle Patient-Centered Care Psychology

Nodding Along

My grandmother was a strong and compassionate Egyptian woman, a mother of three, and a pathologist. On a glass slide, exactly like the ones she used daily, cells from her colon biopsy were identified as undifferentiated, and within days she was diagnosed with Stage IV Colon Cancer.

Although I am learning how to care for people in sickness and health, someday, the chest compressions will be applied to my chest. Disease knows no discrimination, and death unites us all. Thousands of cancer diagnoses and precise and growing knowledge of cancer cell types did nothing to protect my grandmother from that which she knew so much about.

In Egypt, cancer is called ’the bad disease’, and bad it is. Over the next couple months, we watched as the bad disease took our beloved grandmother away from us. During that time, my family members, and my grandmother, had to make a series of challenging decisions that they were very obviously not prepared to make.

Medical advancements, although the main reason we are living longer lives, have caused the complexity and variety of end-of-life decisions to be ever increasing. Uneasy about the series of decisions that my family had to make and handicapped by my ignorance, I found myself reading Being Mortal by Atul Gawande. Atul Gawande led me through a vulnerable and imperfect but inspiring conversation about death and dying, exposing our medical system’s inability to understand health beyond the one-dimensional, and presumptuously noble, endeavor to prolong life at any cost.

While reading Being Mortal, I found myself enthusiastically nodding along, agreeing with the theme of the book: we need to change everything about our simple but destructive approach to aging and our increasing elderly population. Our singular approach to prolonging life simplifies complex social and medical decisions. It seems the attitude now is that longer life is all that matters. Ensuring nutrition and shelter is our only standard for a viable living environment for the elderly. We are failing our parents and grandparents.

Atul Gawande’s presentation of ideas changed how I perceive aging and our healthcare decisions at the end of life. I became a strong advocate of having conversations about the inevitability of our death and the choices we want to be made during our end-of-life care. I was convinced that society and healthcare should ensure that the elderly remain the authors of their own stories for as long as they are willing, and actively empower them to do so. Nutrition, shelter, and minimizing fall risk are minimums of care, not acceptable standards.

The Literature in Medicine Student Interest Group at my school decided to read Atul Gawande’s Being Mortal, and I could not be more excited. In the middle of our meeting discussing the book, as I was passionately sharing my ideas, it occurred to me that although I was full of strong opinions, I had done absolutely nothing to be a part of the solution. My grandfather had come to live with us after his wife of 55 years, my grandmother, passed away from colon cancer, and my only roles/concerns in his care have been to ensure food, sleep, and meds. My strong opinions had not inspired my actions.

Nodding along to Atul Gawande’s criticisms of our medical system is easy, but having an honest conversation with my grandfather about his priorities and end-of-life care preferences as he reaches 90 years of age is not so easy. How might I empower my grandfather to continue to be the author of his story? Believing that healthcare is a right and not a privilege is easy, but carrying out the responsibility that this belief invokes is not so easy. How might I work to help provide all my neighbors with equal access to high-quality care? Practicing the invaluable intervention of presence is not easy, and working day after day to hone my abilities at the art of empathy is not easy. How might I overcome my doubts, fears, and insecurities, and avoid being frozen into lack of compassion?

Too often my strong opinions do not inform my actions. Too often my hate for dysfunctional and unjust systems overshadows my love for the people in the systems. I call myself to love my neighbors more than hate the systems, for love is actionable and hate is stifling and tiresome. Let love fuel the tank, for compassion-based activism is the only kind that goes the distance.

Photo Credit: Dan Strange

Categories
Reflection

The War Against Aging

‘Back in elementary school, I realized we all have a genetic, lethal disease called aging. I remember being frightened that my mother would die and terrified that my existence was ephemeral and meaningless. At the time, it felt like I was being told I had terminal cancer or some other horrible disease. Death was inevitable. No matter how rich or successful I could be in life, it would all be lost in the end. So, still a child, I found an objective, a purpose for my life: to cure human aging.’
Joao Pedro de Magalhaes (1)

Of all the diseases we have left to conquer, one raises its voice above all others: the disease of aging. From anti-wrinkle creams to advertising billboards, from our conceptions of beauty to our desire for youthful skin, our fear of aging is present in all walks of life.

But is aging a disease? Is it a demon that must that be conquered, lurking beneath our skin, crumpling up our genes until our skin sags and our hair turns grey? Or is it a natural part of life – something that needs to embraced with humility? Is our preoccupation with aging a cultural phenomenon, a type of ignorance or obsession that needs to be tackled by changing social attitudes, or is it primarily a problem of medical science?

Eternal Youth vs Immortality

What is it that we are actually fighting for – do we want to live forever, or do we want to be forever young? Most of us would not wish to live a longer life if it meant we continued to age. What we long for is a good quality of life while still holding on to more years. This is best highlighted in the Greek myth known as Tithonus Error. Tithonus was a mortal who was granted immortality by Zeus but was not granted eternal youth. As a result, Tithonus became increasingly debilitated and demented as he aged (2). This is a fate no one would wish to have. The quest, it seems, is to extend one’s years upon this earth while retaining quality of life, looks, and independence. If this is so, we must ask ourselves: is this something worth fighting for?

One argument against the idea of ‘fighting aging’ is the concept that aging is a natural process. For those making this argument, the insistence on limiting aging is uncomfortable; who are we to go against nature? In fact, some would even argue that it is aging that makes us human. Indeed, without the knowledge of mortality placed upon our fragile shoulders, we would never value those things which are so important in our lives and yet so transient – our first kiss, our first day at school, our first date. If we were to extend our lives infinitely, then the value of the present moment may disappear.

As emotively tempting as this argument may be, if one takes a step back and takes a look at the history of medicine, one begins to see that battling nature is something that science has always done; from antibiotics to vaccinations, from the eradication of smallpox to the application of technology, fighting the natural world is an inevitable component of science. Indeed, battling the features of aging makes up a large part of modern-day medicine; we battle stroke and heart disease, insidious cancers, and debilitating degenerative diseases every day within our hospitals and with our surgeries. What makes ‘fighting aging’ any different?

The Cultural Phenomenon

This question ultimately goes back to the cultural phenomenon of aging. Aging is a rather new phenomenon. At the beginning of the 20th century, only 5% of the population was over 65 years of age, while today people are able to lead active and independent lives well into their 90s (3). With this rise in aging has come new prejudices and stereotypes. It has been argued that our negative attitudes against ageing emerged relatively recently, in the 18th century. Prior to this era, the elderly were often held in high regard, seen as carriers of wisdom and knowledge thanks to their years upon this earth. But as more and more people began to survive into their 80s and 90s, the idea of being a ‘nuisance’ began to take hold. Employers felt that the elderly were holding on to jobs that could be taken over by the “young and fit.” This change in attitude is reflected in our vocabulary with words such as ‘codger’ (meaning an odd, old fellow), and the change in meanings of certain words over time, such as ‘fogey’, which previously meant a wounded war veteran but now is used more pejoratively to describe those who are old and thought to hold ‘old-fashioned’ views.

The social role of the elderly has changed dramatically as well. With fewer multigenerational families living under one roof, the role of the elder within the family structure has been lost (3). This gradual change in society is reflected in the way we view age. We equate youth with beauty and aspire to look as young as possible. Yet on a grander scale, the way we view age has also corresponded to a larger shift in our society’s policies, in our public expenditures, and in our healthcare.

Within medical care, conditions such as depression are often ignored in the elderly and often seen as a part of aging itself. From a social perspective, discrimination in social care is evident in the assumptions that people may have about how older people should live their lives and what constitutes a life worth living for the elderly. On a public health level, there is a strong suspicion that the use of Quality Adjusted Life Years, a tool used in the UK to assess the costs of treatments, will often discriminate against treatments for diseases such as Alzheimer’s Disease, Osteoarthritis and Age-related Macular Degeneration, most of which would mainly benefit older people with few remaining years. Within the research sphere, the elderly are often excluded from clinical trials, with this under-representation of the elderly affecting the number of available treatments for them. Most importantly, from the patient’s perspective, older people are more likely to feel talked over compared to other patients when they are in the hospital, often feeling ‘as if they weren’t there’ (5). All of these examples illustrate how our culture of youth has manifested itself within the sphere of medicine, where it is our responsibility to be non-judgemental. Yet this is the world in which we live. If we want to make a change, we must become aware of such uncomfortable realities and understand what has given birth to them.

Even if we wish to view aging as a biological phenomenon, for example by looking for “anti-aging” genes within our laboratories and for drugs that can reverse the damage done to DNA over time, we still have to take into account society’s perception of the elderly. We still have to ask the difficult, philosophical questions. For example, are we battling aging because it will allow us to be healthier and have more fulfilling lives, or because of our modern obsession with youth and beauty? Likewise, how would we evolve or change as human beings if we were able to slow, stop, or even reverse the process of aging?

Perhaps conquering aging is not the same as vanquishing cancer, for growing old is an intricate and natural part of our lives. Indeed, perhaps it is part of what makes us human. These are questions that no one person can answer, and which need to be debated within the public sphere. The discussions that arise from asking these questions will undoubtedly impact the direction medicine takes with respect to its interaction with aging; maybe more resources will be dedicated to ‘diseases of the elderly’. If we are lucky, maybe this will all cultivate an attitude of acceptance and empathy within a culture that sees aging as a part of life. Maybe we can change a culture. Maybe we can even save a life.

“We have added years to life; it is time to think about how we add life to years.”
Robert Kennedy (6)

 

References

  1. Magalhaes, J. P. Fearing Death and Curing Ageing [Online]. Available at: http://www.senescence.info/death_and_aging_fears.html [Accessed: 14th September 2016]
  2. Magalhaes, J. P. Should we cure Ageing? [Online]. Available at: http://www.senescence.info/physical_immortality_myths.html [Accessed: 14th September 2016]
  3. Big Picture. 2014. Ageing and Society [Online]. Available at: https://bigpictureeducation.com/ageing-and-society [Accessed: 30th September 2016]
  4. Jones, R. 2007. A Journey through the Years: Ageing and Social Care. Ageing Horizons. 6: 42-51
  5. Centre for Policy on Ageing. 2009. Ageism and age discrimination in secondary health care in the United Kingdom. Department of Health.
  6. Steinsaltz, D. 2016. Become the New 60;. Nautilus; 36 [accessed 28th May 2016]. Available from: http://nautil.us/issue/36/aging/will-90-become-the-new-60

Featured image:
Age by Iburiedpaul

Categories
Clinical Reflection

The Importance of Geriatric Medicine

When the infamous question “what kind of doctor do you want to be?” has been thrown my way, I have typically responded by throwing out three fields of medicine that I currently find interesting: pediatrics, endocrinology, and geriatrics. However, while the usual response includes much satisfaction about 2 of my potential career choices—with lots of oohs and ahhs about the joys of treating children, and the approving nod for endocrinology because, hey, diabetes—the standard, usually skeptical, follow up question I receive is: why would you want to take care of old people if they are just going to die soon anyway? Isn’t that…depressing?

Despite these ageist misconceptions, the importance of the growing need for trained geriatricians in the U.S. cannot be denied. According to the Association of American Medical Colleges, the latest studies are suggesting that by 2025 the number of American baby boomers over the age of 65 will double, and become the fastest-growing age group in the country. This demographic will soon account for 20% of the nation’s population! We can see the practical results of this trend today, as Americans are clearly living longer, requiring assistance in managing chronic health conditions like hypertension, heart disease, diabetes, dementia, etc.

The most alarming fact? The American Geriatrics Society has estimated that 25,000 certified geriatricians are needed in order to provide quality care to this growing population, but currently there are fewer than 7,500 geriatricians in the U.S. In fact, only 44% of the nation’s 353 geriatric fellowship positions are even filled. Geriatrics is considered to be one of the most underrepresented specialties, even though geriatricians have been found to have high career satisfaction.

So, why the disinterest from budding physicians? Financially, geriatrics is often not considered attractive, particularly with nascent residents facing a looming amount of debt right after medical school. Most elderly patients have either Medicare or Medicaid, which have traditionally lower rates of reimbursement for physicians than that of private health insurance. Indeed, geriatricians, despite the extra years of training, have traditionally received less compensation than other subspecialists.

What can be done to help entice young physicians to this challenging field of medicine? While a restructuring of the current reimbursement difficulties would be an ideal fix to this situation, and would help entice young physicians to geriatrics, perhaps more immediately realizable goals should be considered in the meantime. For example, emphasizing the importance of geriatric medicine within medical school curricula is one alternative and realistic way in which to effect change. Students could learn of the intricacies and complexities involved in providing care to this population. This would be particularly relevant for students, as they are the generation of doctors which will be faced with treating a larger population of older individuals, given the statistics mentioned above.

Here is an even simpler idea: help people realize their passion for the field. Dr. Mitchell Heflin, MD, an associate professor of medicine at Duke University School of Medicine, said it best, “People in geriatrics are called to it.” A commonly cited influence for this career choice is meaningful interactions, particularly in childhood, with older populations. I personally can see why I am drawn to this field of medicine, as much of my happiness as a child (and up to the present day), has revolved around my experiences with the elderly. I remember every Sunday I would cross the street and have a spaghetti dinner with our elderly neighbor, affectionately known as Auntie Eva. She was a chain smoking, fiercely opinionated and loving German lady from Buffalo, who could make a killer homemade marinara sauce and meatballs. Even more influential, however, is the relationship I have with my now 83 year old maternal grandmother who has lived with my family since my birth. She not only always babysat me, but also taught me how to fish, ride a bike, tie my shoes, and crochet. Watching her gracefully age with a high quality of life through her 60s and 70s, and then seeing her current struggle with the beginning stages of dementia, has really made me reflect upon the importance of geriatric care in our society and my potential role in it.

So, while I’m not yet sure if geriatrics is in the cards for me, it is obviously a complex field of medicine, critical for the health of the older population and for the health and dignity of our society at large.

 

References:

https://www.aamc.org/newsroom/reporter/april2015/429722/fewer-geriatricians.html

http://health.usnews.com/health-news/patient-advice/articles/2015/04/21/doctor-shortage-who-will-take-care-of-the-elderly

Featured image supplied by the author