by Tyra Phipps, Ed.D. (tyra.phipps@gmail.com)

Dr. Atul Gawande

Dr. Atul Gawande recently published the book, Being Mortal.   The surgeon in the story is also the father of the writer, who is a surgeon and in the picture to the right.  It was a normal day for his father, but a tingling sensation in the surgeon’s hands led to a diagnosis of a spinal cord tumor.  The choices were surgery or wait and see greater debilitation.  The risk was great.  The outcome was sad.  The personal insights from Dr. Gawande revolve around how can we better live with age-related diseases and illnesses?  We will all get more frail with age, so how can we preserve function?  How do we better prepare for death?  Is there a way to try and facilitate well-being as a new philosophy of healthcare?  For so many who have been independent, what happens when there is a change to total dependence on someone else?

Dr. Gawande states, “For many, such talk, however carefully framed, raises the specter of a society readying itself to sacrifice its sick and aged.  But what if the sick and aged are already being sacrificed — victims of our refusal to accept the inexorability of our life cycle?”  Even medical professionals are more concerned with treating diseases than on living.  Diseases can occur at any age and be quite debilitating, but what about the eventuality of old age?  How can a society and medical profession at large help make old age the best part of living?

As Ms. Sheri Funk stated in a review of Being Mortal on November 6, 2014, there are different models of senior living.  The end-of-life medicine needs a better model of care, no matter whether the approach is a multigenerational household, newfangled nursing home, or hospice. 

Why does there need to be a better model of caring for the elderly? 

Mr. Michael Dulin, Composer, Pianist, and Concert Artist wrote on June 9, 2015, “I am fully aware of the nightmare situations in assisted living.  My teacher died last January.  I saw him the day before he died.  He was trying to tell everyone what was going on, but nobody would listen.  He called me and begged me to take him home.  I was leaving the next morning for Los Angeles, and told him that I would come help him first thing when I got back.  I woke up in Los Angeles to a text telling me that he had died during the night.  He was mistreated, malnourished and dehydrated because the staff would not answer his calls.  Very sad.”

On May 20, 2015, Mr. Garth Clark observed, “It must be so difficult to lose control of what, for most of us, are the mundane and routine parts of our day.  To have one’s life in peril in a supposedly safe haven is inexcusable.  I feel tension and frustration just reading about the challenges faced by residents and the lack of empathy and compassion shown by companies in a service industry.”

A Day in Long-Term Care:

What are the routine parts of a day that change significantly after moving to long-term care?  You no longer drive or have a car.  Your belongings are reduced to three drawers, a small closet, a nightstand with a couple of drawers, a shelf, a tray table, and a bed.  In a nursing home, you may have just sixteen inches on either side of your bed.  There may be some room for your favorite chair and if you are lucky, you can look out a window.  There may or may not be a nice view, but it will be the same view that you see for years.  Put on a pair of garden gloves to simulate a lack of coordination of your hands.  Try using a phone or try, texting, combing your hair, brushing teeth, dressing yourself, and tying your shoes.  Put some Vaseline on a pair of glasses and see what it’s like to navigate with distorted vision.  Sit in a chair looking out any window of your choice in your home and imagine staying there for the rest of your life.  The only other place that you can call your own is your bed.  Even then, after a medical issue of any kind, you may be moved to another room or a different facility that may or may not be to your liking.  In most nursing rooms, you share a bathroom.  Privacy is minimal.  Showering or bathing involves a trip down the hallway to the bathing area.  A nursing aide assists you with bathing unless you can bathe yourself.  After the shower, you go back to your own room in full view of everyone else in the hallway.

The morning begins at 5:47 a.m. with the sound of a grating voice on a loudspeaker system saying, “Dietary order on the elevator for North Hall.”  Thereafter, messages bombard the loudspeaker system with carts one, two, three, four, five are on the elevator.  Fine dining carts are ready and lastly, Memory Lane (Alzheimer’s unit) is ready.  These dietary announcements occur three times a day, and that is every day for the rest of your life.  What is on the menu?  For breakfast, a tray arrives in nursing with pasteurized baked eggs and cheese, oatmeal that is watered down, two pieces of toast in a wax paper bag that causes the toast to get soggy, orange juice, and decaffeinated coffee that is lukewarm.  Lunch is an anemic looking, white chicken breast with two teaspoons of barbecue sauce on top, a chopped up boiled potato, and broccoli that was overcooked.  A small piece of carrot cake is the desert.  The evening meal is taco meat on a baked potato, and more broccoli.  The same decaffeinated coffee may be served upon request.  There is always water to drink.  There are also soap spots and residue on the plates, cups, glasses, and cutlery.  The assisted living meals are the same that day with some cantaloupe on the cold bar.  You may eat in the dining area with the people on your floor in assisted living, or stay in your room.

There are loudspeaker announcements throughout the day.  For instance, Scott, pick up line 226, or Julie has a family member online 501.  Activities are announced at 10 a.m. and that can be anything from balloon tennis to a Coke and gab session.  There can also be an exercise announcement for a Monday, Wednesday, or Friday morning.  Various kinds of instrumental music are sometimes played in the background.  Throughout the day, there are more than 25 loudspeaker announcements for various nurses and administrators to pick up on incoming lines.  Call bells ring all day long.  There are a total of 81 loudspeaker announcements that day.   Even though you had assistance and prepared yourself for bed at about 9 p.m. and you have been asleep for probably one half hour, there is a practice fire drill for staff at 11:17 p.m.  Your sleep pattern is disturbed, but you turn over hoping to get five or six hours of sleep before the next barrage of loudspeaker announcements and call bells start the new day.  This is what a day is like in Goodwill Retirement Community located in Grantsville, Maryland.  Do you want to spend the last ten, fifteen, or twenty years of your life that way?   Is this how you want your loved one to live?

An Ombudsman Perspective:

Ms. Terry White, Ombudsman discussed a different approach to life in long-term care facilities on June 17, 2015.  “Having worked in the field and then being an ombudsman, I’ve seen firsthand what’s good and what’s not so good.  Facilities everywhere should be more alike.  The care should be more person centered and staff need to keep in mind their residents are people, not a commodity and treat them as they would want to be treated.  That resident is a person who held jobs, taught our children, raised their own families, traveled extensively, has knowledge about many things and they deserve all the respect and dignity we can give.  The care should be individualized.  The Eden alternative has the right idea.  Sometimes rules and regulations can be tricky but I fully believe if it is done right, you can provide good care in a homelike environment and treat those we care for with dignity.  It’s a team effort.  The team consists of the resident, the doctor, the nursing team, physical therapy, social services, dietary, the activities department and more.  If it’s not being done as a team, then it should be for that is the only approach that works to allow for more personal experience in long-term care.”

How do you prepare for an eventual aging process that may require long-term care?

Ms. Jennie L. Phipps advises having a plan for long-term care.  In the article she reviewed, “Smile, You Can Afford to Retire,” Mr. David Blanchet, Head of Retirement Research at Morningstar Investment Management discusses the fact that the cost of medical care is increasing at more than seven percent per year.  Any expensive healthcare shock can lead to ruin.  While Mr. Blanchet is not especially enthusiastic about long-term care insurance, he recommends figuring out in advance how to cover unexpected costs.  A home, a reverse mortgage, or an outright sale of the home could be part of the answer in an emergency situation.  He also recommends putting aside at least fifteen percent of your income a year (Bankrate.com, June 3, 2015).

Mr. Dave Berry observed on May 21, 2015, “The bottom line in long-term care will always be about dollars and cents.  Any resident is probably no more than a widget.  People in long-term care are captive and at the mercy of the staff and administration.”

On June 9, 2015, Ms. Jane Albertson wrote about the disturbing news of her neighbor who is a nursing aide and recently placed her father in the long-term care facility where she works in Indianapolis.  Doris told Ms. Albertson that the speech therapist had her father on puréed food instead of whole food.  He had no problem swallowing and passed the swallowing test without any difficulty.  The nursing home said otherwise.  Doris got the report from the hospital.  Despite trying to correct the situation for her father’s feeding, Doris complained that everything fell on deaf ears.  She brings food from home, fast food, or anything else her father wants to eat.  The only thing she can do is oversee everything that happens to her father because luckily, she works in the facility where her father resides.

Ms. Janice Bond commented on April 29, 2015, “My family has been blessed.  My dad had Alzheimer’s, but my mom kept him at home the whole time.  She is an amazing woman.  I have six siblings and we promised her that we would never put her in a nursing home either.”

Mr. David Cravey was happy to shed some positive light for better delivery of services in long-term care.  On May 28, 2015, Mr. Cravey said, “My sister works as an licensed practical nurse, and made a suggestion for better utilization of her position in a meeting with the director of nursing.  My sister is now responsible for checking patients on her floor daily to see that they have been bathed, sheets change, medicated and ask if they have any concerns.  This has been implemented for several weeks and the patient satisfaction surveys have shown dramatic improvement.  When people are held accountable, see what happens.  I’m really proud of my sister.”

The Business Perspective:

Mr. Christopher Markowski, Wall Street Watchdog was interviewed on NPR during the month of June, 2015.  In the interview, he said that it is not the organization, it is not Wall Street but the people who work there engaged in wrongdoing who we need to go after.  From Newsmax.com, Mr. Markowski says, “A company is nothing without its employees.  People are responsible for the everyday operations of an organization, including wrongdoings.  Wall Street has been in need of a sense of ethics for too long, and it's starting to show.  Employees engaging in shady business practices are able to hide behind the company's façade and avoid the repercussions of their actions, which just furthers this problem.  If a company is in trouble for its employee’s actions, why are those employees not being prosecuted or fired?”  Should the Wall Street watchdog approach apply to long-term care delivery of services?  Should good employees working at every level in long-term care be rewarded?  Is there a corollary with irresponsible healthcare workers at every level in long-term care facilities hiding behind a big façade of the beautiful building and avoiding the repercussions of wrongdoings?  Even though Mr. Markowski is writing about Wall Street, is there a crossover to the healthcare industry?  Is long-term care in need of vigilant watchdogs and accountability to eradicate employees engaging in shady practices?

Questions for Consideration:

1.  Dr. Raj reported on the Today Show, June, 2015, about the dangers of the two hours in the day for heart attack and stroke.  Circadian rhythms leave us the most vulnerable at 6 a.m. and 9 p.m.  This is because cortisol is the highest in the body during those times of the day.  She recommends never rush at 6 a.m. because it can bring on a heart attack or stroke.  Oddly enough, this is the busiest hour before the 7 a.m. shift change in any long-term care facility.  The most vulnerable residents in long-term care are rushed the most.  Blood pressure is the highest at 9 p.m. according to Dr. Raj, yet that frequently is the hour following a medicine pass that residents with hypertension get blood pressure readings.  How accurate is that BP reading?  Is there a better way to personalize long-term care?  The research by Dr. Roshini Raj from June, 2015, is called, “The Darkest Hours:  Certain Times of Day Can Be Hazardous to Your Health.” In her work, Dr. Raj explains how our circadian rhythms affect our health.

2.  In the book, The Body Keeps the Score:  Brain, Mind, and Body in the Healing of Trauma, published in 2014, Dr. Bessel van der Kolk writes about the need to deal with trauma.  He cites of many examples but emphasizes one common theme.  Following trauma of any kind, what is it the patient wants to do, or get back to doing.  For instance, the response may be that the patient wants to make love to his spouse, or get back to work, or just live in the moment rather than reliving the posttraumatic stress.  Not dealing successfully with trauma means living in the past and depression.  This physician states that there is a quiet revolution going on and there are good healthcare providers promoting health and treating people with dignity and respect. 

3.  Dr. J. Gary Sparks, a Jungian Analyst located in Indianapolis, Indiana, with more than forty years in private practice, succinctly summarized the state of long-term care and society at large with the words, “No hope.  The world is dying of dysfunction.  Incompetence, not the Russians, not the Islamic fundamentalism, not North Korea, will be our undoing” (May 12, 2015).  Dr. Sparks’ mother is in her mid-90s and is considering relocating to an assisted living facility outside of Lancaster, Pennsylvania.  She previously had rehabilitation in what turned out to be one of the poorest rated nursing homes in Pennsylvania. 

June, 2015