Hi all,
Last week, I wrote about Atul Gawande’s Being Mortal and briefly explored his insights into end-of-life options for terminally ill patients. One important angle I did not look at was hospice care. Unlike standard medical care, hospice care differs because the goal of treatment is not to extend life but rather to help the patient have the best possible day.
The thing that makes hospice such an important option for many patients is how the goal of care aligns with how people’s preferences tend to change as they age or become sick. For the most part, people’s social networks narrow over time as their dwindling horizons force them to focus more on the present than on the future. Rather than seeking to broaden their experience, people start to prefer the care and companionship of what they already know. Hospice care recognizes these preferences and tailor treatment to help patients focus on being rather than doing.
However, this approach does not suit everyone medically eligible for the hospice benefit. As we build up our system of non-treatment options for our aging population, the challenge facing hospice is to preserve the core of its treatment philosophy while expanding its horizons to meet the needs of those whose preferences do not align so well with the general ideas described above. As a hospice volunteer, it’s a challenge I look forward to meeting every time I start a shift.
Being Mortal also boasted a few good nuggets of information for helping amateur caregivers like me learn how to better interact with patients. Gawande points out how it is important to account for spine curvature when helping others eat. The elderly are more likely to have curved spines and therefore should eat looking down – if they look straight ahead, it quickly becomes a choking hazard because a person with a curved spine looking straight ahead is like anyone else looking up at the ceiling.
Also, I liked the recommendation that those who struggle to help others make good decisions during difficult situations might do well to simply try and explain their worry next time. I imagine this is due to how we never know quite as much about how another person is thinking or feeling as we like to think. The approach of expressing your own feelings can do wonders in such situations to help others understand why you are recommending a particular course of action.
Not all of the insight was purely medical. I liked some of the advice presented for how to interact with others in order to help them feel heard. First, it is important to sit or stand at eye level. There should be no desks, screens, or even tables between you and the other. Also, try not to twitch, fidget, or move around as the other person speaks. Finally, when the other person has stopped speaking, pause for a beat to confirm that the other person has stopped speaking.
One up: Gawande scatters surprising statistics throughout Being Mortal. He notes, for example, that genetics do not have the same influence on longevity as they do on other attributes – whereas height is around 90% explainable by genetics, longevity is measured at around 3%.
I also learned quite a bit from his comments about falling. A fall is one of the loudest possible alarm bells for aging or sick Americans. The biggest risk factors are poor balance, muscle weakness, and taking more than four prescription medications. A person without those risk factors has a 12% fall risk but those with all three are at close to 100%.
Some of the other uses of statistics lacked the precise numbers of the previous examples yet were instructive in their own way. One statistic showed that doctors massively overestimate their patients’ survival times. Interestingly, the likelihood of an overestimate went up the better the doctor knew the patient.
A final thought is a great summary of how statistics work in general – the variation around the middle point tells a richer story than the middle point itself. I think this insight speaks to the struggle many have when trying to pull meaningful insights out of a dataset. I think people are very capable of understanding absolute or binary metrics but have a tougher time interpreting (and applying) the lessons embedded in the variation around the midpoint.
One down: Gawande's insights into the problems of geriatricians spoke volumes about the larger problems in the medical field. This specialty does not have a natural niche in the modern medical marketplace because it does not offer to fix anything. Instead, geriatricians will help their patients increase resilience in old age and have incrementally better days in the future. This sounds nice on a silly little space like TOA but at a societal level our priorities have yet to value this approach. Until we do this, our best and brightest will continue to pursue more lucrative ventures like specialty surgery, computer programming, or shooting three-pointers.
The comments about geriatrics reminded me of an article I read years ago about the challenge of being a primary care physician. The overall thought was similar to what I’ve just highlighted about geriatrics. I still remember a line from the piece – the challenge of primary care is trusting that your patients will come back if their symptoms get worse. In ‘the modern medical marketplace’, it is hard to think of a good way to reimburse doctors who can earn their patients’ trust, right?
Just saying: I thought the idea that living things offer an alternative to boredom simply because of their spontaneity was a very effective way to explain the importance of something most of us feel no need to explain. It isn’t necessarily important to explain everything we take for granted, of course, but I think it is a useful habit to get into because being able to articulate important concepts with simple explanations is the essence of helping others understand the world.
