Monday, September 22, 2014
What to Bring to a Nursing Home (when you or your family are checking in). Job applicants will follow next week.
Okay, we know you don't want to go, but maybe you need a little extra rehab or don't have anyone to stay with you 24/7 after surgery. All skilled nursing facilities have a cumbersome admission process that has many different people asking the same questions and you aren't really at your best. Somewhere in the pile of papers you are given, there's a list of stuff you should bring with you, but you may not feel like reading. Besides, you probably haven't had time, since your hospital social worker gave you only a couple hours notice to figure out what to do and where to go, then your transportation arrived and you were out the door to a place you told your family you'd rather not be.
On that list there are the usual things; work-out clothes or sweat pants that are easy to put on but give you a little dignity, good shoes with solid soles (not slippers), p.j.'s and robe, your glasses, hearing aids, or whatever accommodations you use at home to help you operate better, and so on. If you shave, bring an electric razor, even if you don't normally use one. That way you can do things for yourself that will help you feel a little more independent. And somewhere in the fine print, you are advised to write your name on all your stuff so that when it goes missing, we can get it back to you.
Here are things that aren't on the list, but may make your stay a little nicer. Bring your iPod or MP3 player with your favorite music and a good set of head phones (you can also download books to listen to). If you don't have one, ask your grandkids to bring you one and have them help you load it with what you might like to listen to. If you are a computer tablet user, bring that. You can download games, brain exercises, emails, follow your facility on Facebook, and otherwise, keep yourself engaged, active and in touch with the world you are missing. Maybe you have a smart phone? Bring whatever mobile device you use because although your room may come with a phone, it won't have all the numbers you usually use and your family will find it easier to keep in touch, too.
Bring a picture of family, friend, and/or pet--whoever will most motivate you to get better and get home. Ask your family to bring your knitting, crocheting, scrapbooking, jewelry making, musical instrument (every place has a piano, so don't worry about bringing in a keyboard)--whatever gives you pleasure when you have time or inclination to get around to it. If you can't manage those things just now, be sure to let the activity staff know so we can find similar activities to keep you occupied in ways that are meaningful and therapeutic for you.
Personally, I never go anywhere without a head lamp. People may laugh at me, but I can read or answer emails, surf the net, or whatever, without disturbing my husband. You may have a roommate who despite the privacy curtain, complains about any light. Head lamps are available just about anywhere that sells flashlights and they are most helpful when a little extra light is needed. Don't worry about feeling like a crazed miner. Once everyone sees how nice it is to see hands-free, they won't be laughing. About the television...many facilities have headphones you can borrow for the television so as not to bother others. If you have them, bring them and we'll set you up. Likewise, if you have a library card, bring it. Library volunteers are in every week and you can check out both audio books and large print books from them.
Here are a few things not to bring. No matter how much of a coffee snob you are, don't bring your Kuerig or coffee maker. We have regulations about temperatures of liquids and ratings of electronics so you likely aren't going to be able to use it. Don't bring in your prescriptions from home. We're not trying to make you buy more medicine, but again, our regulations require we order your medicine so that we know it is what the label says, the expiration date and so on. Don't bring in food or liquor. You may or may not be able to keep your favorites in your room, but again, regulations require we check with your doctor before we can let you enjoy your favorite 'guilty pleasure.' Most facilities have 'no smoking rules.' It's not just a good idea, it's the law. This is a great time to quit, but if you can't, your doctor can order patches or other aids to help you get through your stay. If you happen to be a marijuana user, don't bring that either. We have to operate under federal guidelines, so regardless of Washington State law, we can't accommodate you.
Keep your money, your expensive jewelry, your credit cards or things of that nature at home. All facilities have a safe in which you can lock things if you need, but best to have someone take them home. Be sure to record what went home too, because being 'under the weather' can play havoc with memory, and your family and friends may have so much on their minds, they may not recall either. Keeping a notebook and pen by your bed are handy for reminders for you and/or your visitors to note what goes home, what comes in from home, and helps keep track of flowers, guests, staff names or questions you'd like to ask your doctor or nurse.
Having to spend a few extra weeks with us in a skilled nursing facility may seem like a step backward, but it often is the best way to make sure that you don't end up back at the hospital. Bringing a few of the comforts of home, whether it's a favorite pillow or quilt, will help you get better faster...and get back where you want to be. Happy Healing!
Monday, September 8, 2014
Does Six Second Exercise Trend Work? (Fingers crossed)
I was trying to figure out what to blog about this week. I thought about "sex and the septuagenarian"(for my older friends, of course. My son suggested I write about sleep since there are plenty of studies on our need for it, even as we get older. (If you are hoping I am going to comment on his focus on (lack of sleep) or my focus on sex, I’m sure it’s purely co-incidental.) Ultimately, I asked my step-daughter who is wise in more ways than I have ever been. Her suggestion: "That six second exercise stuff that's all over the place is what I want to know about. Does that really do any good?"
To be honest, I haven’t followed the” six-second" exercise program. Had I been paying more attention, I wouldn’t have been slaving away for at least half an hour of heavy breathing and sweating every day. (We are still talking about exercise here.)I’d love a faster regimen-- even sixty-seconds, let alone six. Here’s what I found regarding the six second craze.
According to Newser (newser.com), a study from Abertay University in Scotland had twelve people over sixty do six seconds of high intensity exercise on a stationary bike, followed by at least a minute of rest. They progressed to repeating this ten times. The participants had a 9% decrease in blood pressure and discovered an easier time walking their dogs. The article states, " The broad message is you are never too old, too frail, too ill to benefit from exercise, as long as it is carefully chosen.
Dr. Oz's new magazine, The Good Life, promises that ten basic moves is all it takes to fix many problems. I quote , “ Do this set of ultra basic moves in the time it takes to brew a cup of coffee. You'll transform your body, bolster your health, and make exercise a joyful habit." Oz suggests you add 5 exercises or 5 seconds per week per exercise. . The plan begins with 100 seconds, 10 exercises times 10 reps the first week, and progresses to 250 seconds; 10 exercises times 25 reps by week four. My anecdotal experience is that if I miss even a few days of strength or flexibility type work on myself, I not only fail to see gains but find myself headed in the other direction. This body does not rebound or retain strength and flexibility like it used to.
Here's what the 'experts' at The Center for Disease Control recommend:
" Older adults need at least:
2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
or
1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and
muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
or
An equivalent mix of moderate- and vigorous-intensity aerobic activity and
muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms.”
They continue:
“10 minutes at a time is fine. We know 150 minutes each week sounds like a lot of time, but it's not. That's 2 hours and 30 minutes, about the same amount of time you might spend watching a movie. The good news is that you can spread your activity out during the week, so you don't have to do it all at once. You can even break it up into smaller chunks of time during the day. It's about what works best for you, as long as you're doing physical activity at a moderate or vigorous effort for at least 10 minutes at a time."(cdc.gov)
A recent article in Arthritis Care & Research By Daniel White, PT, ScD, and his colleagues, found that older persons with osteoarthritis in their knees benefit greatly from walking with a goal of 6000 steps per day. Participants improved and maintained function but an increase of even 1000 steps/day reduced the chance for developing functional problems. It takes longer than six seconds though.
The clinical evidence is pretty clear. I regret to inform you that appears the six second thing is not going to be the panacea for functional maintenance or optimal health. However, for you my brilliant step-daughter, the experts agree--any exercise, even six seconds of it, IS better than nothing.
To be honest, I haven’t followed the” six-second" exercise program. Had I been paying more attention, I wouldn’t have been slaving away for at least half an hour of heavy breathing and sweating every day. (We are still talking about exercise here.)I’d love a faster regimen-- even sixty-seconds, let alone six. Here’s what I found regarding the six second craze.
According to Newser (newser.com), a study from Abertay University in Scotland had twelve people over sixty do six seconds of high intensity exercise on a stationary bike, followed by at least a minute of rest. They progressed to repeating this ten times. The participants had a 9% decrease in blood pressure and discovered an easier time walking their dogs. The article states, " The broad message is you are never too old, too frail, too ill to benefit from exercise, as long as it is carefully chosen.
Dr. Oz's new magazine, The Good Life, promises that ten basic moves is all it takes to fix many problems. I quote , “ Do this set of ultra basic moves in the time it takes to brew a cup of coffee. You'll transform your body, bolster your health, and make exercise a joyful habit." Oz suggests you add 5 exercises or 5 seconds per week per exercise. . The plan begins with 100 seconds, 10 exercises times 10 reps the first week, and progresses to 250 seconds; 10 exercises times 25 reps by week four. My anecdotal experience is that if I miss even a few days of strength or flexibility type work on myself, I not only fail to see gains but find myself headed in the other direction. This body does not rebound or retain strength and flexibility like it used to.
Here's what the 'experts' at The Center for Disease Control recommend:
" Older adults need at least:
2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
or
1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and
muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms).
or
An equivalent mix of moderate- and vigorous-intensity aerobic activity and
muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms.”
They continue:
“10 minutes at a time is fine. We know 150 minutes each week sounds like a lot of time, but it's not. That's 2 hours and 30 minutes, about the same amount of time you might spend watching a movie. The good news is that you can spread your activity out during the week, so you don't have to do it all at once. You can even break it up into smaller chunks of time during the day. It's about what works best for you, as long as you're doing physical activity at a moderate or vigorous effort for at least 10 minutes at a time."(cdc.gov)
A recent article in Arthritis Care & Research By Daniel White, PT, ScD, and his colleagues, found that older persons with osteoarthritis in their knees benefit greatly from walking with a goal of 6000 steps per day. Participants improved and maintained function but an increase of even 1000 steps/day reduced the chance for developing functional problems. It takes longer than six seconds though.
The clinical evidence is pretty clear. I regret to inform you that appears the six second thing is not going to be the panacea for functional maintenance or optimal health. However, for you my brilliant step-daughter, the experts agree--any exercise, even six seconds of it, IS better than nothing.
Tuesday, September 2, 2014
Who me? Not me! An incontinent blog
When my youngest son was enrolled in his first college sociology
class, he called to ask advice about an assignment he felt was baffling. "I need
to spend the day as some kind of 'social deviant' like in a wheelchair or blind
or....you know, different."
"Easy," I told him, "pour some water on the front of your
pants."
"Huh?"
"See how people treat you if they believe you peed your
pants."
It's possible that only a mother who has spent much of her life among
old people would realize that something as common as urinary incontinence has
huge social implications for the person experiencing it. And it is
common.
The U.S. Department of Human Services reported that approximately 13
million people in the United States were incontinent in 1998. Women are far more
likely to be incontinent than men. In fact, one out of four of us between the
ages of 30 and 59 will pee our pants often enough to be considered incontinent.
You can imagine what the addition of more years and a little extra weight can
do. At eighty, one out of every two of us will be incontinent. It's estimated
that 80% of the nursing home population is incontinent. In fact, it's a big
reason why people can no longer be cared for at home.
Back when I was in
graduate school, my primary adviser, who seemed ancient and not very cool to me
then, suggested and then demanded that I put at least half my intellectual and
clinical efforts into understanding and finding interventions for incontinence.
I didn't find it an appealing idea. I imagined being asked what I was studying
at a social gathering and finding myself in a conversation gone silent. Nobody
was talking about it and nobody wanted to. In those ancient times, the aisles of
Walgreen's were not prominently displaying products guaranteed to help those who
leak from anywhere at anytime of any solid or liquid, instant social
acceptability. Now there are even over-the-counter medications to deliver us
from humiliation if the need to go outruns the distance to the toilet.
As has
often happened over the years, my adviser turned out to be neither cruel nor
stupid. Had I adopted her direction whole-heartedly, I would likely be a
zillionaire and/or writing a blog for the National Institutes of Health. But I
learned enough, and have been grateful for her insistence since that first day
long ago that I landed my first acute rehabilitation job.
We spent $16.3
billion dollars on incontinence products in the U.S. in 2001. Judging by both
the amount of goods at the store and the amount of ads in magazines, we're
probably spending a lot more than that now. It seems incontinence has come out
of the closet. Or has it?
Here's the good news. Doctors routinely ask about
elimination issues now when you go in for your annual check up. Or at least the
the good primary care physicians do. There are many more medicines and/or common
surgical procedures available, so it isn't necessary to just "accept the way it
is" and drive yourself to the drug store. It's possible that even if the problem
can't be fixed, it can be managed better than resigning yourself to adult
diapers. But that's the problem, isn't it? Diapers.
We learned we weren't
babies anymore when we graduated to big girl panties (or big boy boxers or
whatever). That was likely the last time any of us was publicly congratulated
for announcing our progress in controlled defecation. If you are a certain age,
you were shamed by your mom or your whole neighborhood if you wet the bed at
night. Neither your mom or you was likely to discus the problem with your
pediatrician because it was thought to be more of a behavioral problem than a
medical one. Elimination in this culture has never been the subject for dinner
table conversation or public acknowledgement. We call the rooms in which these
things happen "rest" rooms or "wash" rooms--although in my experience neither of
those happen very often in there. You get the point.
The first time you wet
your pants as an adult you figure you might as well move to a deserted island
where you can pee when the need arises and nobody will judge you. You might, if
you are enlightened, get yourself to your family doctor if it keeps happening,
but you are not likely to talk about it with anyone else. It not only feels
physically uncomfortable, it feels like failure and it is shameful. When it
happens to you it doesn't matter how common, how many products and ads or how
educated you are about how things work. It's devastating.
Most nursing homes
aren't much help. Incontinence is so common in skilled facilities that we may
put you in products whether you might have been able to make it, if only you
could walk to the toilet by yourself, or not. We are professionally impersonal
about helping you into clean clothes so as not to acknowledge how humiliated you
feel, how demoralized. We don't ask about it, not when it started, not what
makes it better or worse or any of those fundamental assessment questions we ask
about your other physical problems. Some things haven't changed. Nobody is
talking and nobody wants to. Don't accept this.
Here's the thing. When I was
a kid in nursing school, they made us watch a movie titled, "Nobody ever dies of
old age." The same might be correlated to incontinence. Something can and
should be done to improve things if you are experiencing it. Failure to control
those sphincters does not mean personal failure. And if you aren't sure who to
talk to, ask a rehab nurse. It's our specialty. If you or your family are
needing our kind of service, ask the places you tour about restorative
continence programs. If the answer is "toileting q 2," find another place.
Skilled restorative nursing is much more than that. And whether you are in a
health care setting or not, talk about it. It's time for a change...and not just
of underwear.
class, he called to ask advice about an assignment he felt was baffling. "I need
to spend the day as some kind of 'social deviant' like in a wheelchair or blind
or....you know, different."
"Easy," I told him, "pour some water on the front of your
pants."
"Huh?"
"See how people treat you if they believe you peed your
pants."
It's possible that only a mother who has spent much of her life among
old people would realize that something as common as urinary incontinence has
huge social implications for the person experiencing it. And it is
common.
The U.S. Department of Human Services reported that approximately 13
million people in the United States were incontinent in 1998. Women are far more
likely to be incontinent than men. In fact, one out of four of us between the
ages of 30 and 59 will pee our pants often enough to be considered incontinent.
You can imagine what the addition of more years and a little extra weight can
do. At eighty, one out of every two of us will be incontinent. It's estimated
that 80% of the nursing home population is incontinent. In fact, it's a big
reason why people can no longer be cared for at home.
Back when I was in
graduate school, my primary adviser, who seemed ancient and not very cool to me
then, suggested and then demanded that I put at least half my intellectual and
clinical efforts into understanding and finding interventions for incontinence.
I didn't find it an appealing idea. I imagined being asked what I was studying
at a social gathering and finding myself in a conversation gone silent. Nobody
was talking about it and nobody wanted to. In those ancient times, the aisles of
Walgreen's were not prominently displaying products guaranteed to help those who
leak from anywhere at anytime of any solid or liquid, instant social
acceptability. Now there are even over-the-counter medications to deliver us
from humiliation if the need to go outruns the distance to the toilet.
As has
often happened over the years, my adviser turned out to be neither cruel nor
stupid. Had I adopted her direction whole-heartedly, I would likely be a
zillionaire and/or writing a blog for the National Institutes of Health. But I
learned enough, and have been grateful for her insistence since that first day
long ago that I landed my first acute rehabilitation job.
We spent $16.3
billion dollars on incontinence products in the U.S. in 2001. Judging by both
the amount of goods at the store and the amount of ads in magazines, we're
probably spending a lot more than that now. It seems incontinence has come out
of the closet. Or has it?
Here's the good news. Doctors routinely ask about
elimination issues now when you go in for your annual check up. Or at least the
the good primary care physicians do. There are many more medicines and/or common
surgical procedures available, so it isn't necessary to just "accept the way it
is" and drive yourself to the drug store. It's possible that even if the problem
can't be fixed, it can be managed better than resigning yourself to adult
diapers. But that's the problem, isn't it? Diapers.
We learned we weren't
babies anymore when we graduated to big girl panties (or big boy boxers or
whatever). That was likely the last time any of us was publicly congratulated
for announcing our progress in controlled defecation. If you are a certain age,
you were shamed by your mom or your whole neighborhood if you wet the bed at
night. Neither your mom or you was likely to discus the problem with your
pediatrician because it was thought to be more of a behavioral problem than a
medical one. Elimination in this culture has never been the subject for dinner
table conversation or public acknowledgement. We call the rooms in which these
things happen "rest" rooms or "wash" rooms--although in my experience neither of
those happen very often in there. You get the point.
The first time you wet
your pants as an adult you figure you might as well move to a deserted island
where you can pee when the need arises and nobody will judge you. You might, if
you are enlightened, get yourself to your family doctor if it keeps happening,
but you are not likely to talk about it with anyone else. It not only feels
physically uncomfortable, it feels like failure and it is shameful. When it
happens to you it doesn't matter how common, how many products and ads or how
educated you are about how things work. It's devastating.
Most nursing homes
aren't much help. Incontinence is so common in skilled facilities that we may
put you in products whether you might have been able to make it, if only you
could walk to the toilet by yourself, or not. We are professionally impersonal
about helping you into clean clothes so as not to acknowledge how humiliated you
feel, how demoralized. We don't ask about it, not when it started, not what
makes it better or worse or any of those fundamental assessment questions we ask
about your other physical problems. Some things haven't changed. Nobody is
talking and nobody wants to. Don't accept this.
Here's the thing. When I was
a kid in nursing school, they made us watch a movie titled, "Nobody ever dies of
old age." The same might be correlated to incontinence. Something can and
should be done to improve things if you are experiencing it. Failure to control
those sphincters does not mean personal failure. And if you aren't sure who to
talk to, ask a rehab nurse. It's our specialty. If you or your family are
needing our kind of service, ask the places you tour about restorative
continence programs. If the answer is "toileting q 2," find another place.
Skilled restorative nursing is much more than that. And whether you are in a
health care setting or not, talk about it. It's time for a change...and not just
of underwear.
Wednesday, August 27, 2014
Is it a 'senior moment' or something to worry about?
More and more I find a blank spot where a word, a name, a book title, or a phone number should be. Even though I have been a student of all manner of dementias and brain dysfunction, there's a little voice inside my head that wonders, "Is this the beginning of something progressive and very depressing?" I reassure myself that I"m over-tired, stressed, or multi-tasking too much, but to be honest, the reassurances aren't very successful. I double up on brain apps on my phone, workouts with my trainer and organic vegetables--all in the hopes that the next time I lose something like a word, my cell phone, or my car keys, I'll find them in a second instead of spending the next few hours trying to remember what the name of that song was I loved back in high school. The worry persists.
I found some reassurance lately, thanks to a recent white paper on memory issued by Johns Hopkins University School of Medicine. (www.johnshopkinshealthalerts.com/alerts_index/memory/23-1.html) The author, Dr. Peter Rabins writes (a) "reassuring difference between normal forgetfulness and dementia is that people who worry about memory loss are unlikely to suffer from a serious memory condition. By contrast, people who do have a serious memory impairment tend to be unaware of their lapses, do not worry about them, or attribute them to other causes."
Okay, I do use that "not-enough-sleep, too-much on my mind" excuse a little too much. At what point should I or any of us start to think about seeing a doctor? Rabins states, "If there are activities that a person has always done but now has difficulty doing, then it's time for a professional assessment."
To Rabins' point, I thought about talking to my primary care doctor about the fact I can't stay up all night like I used to always do when the need arose, but I have a feeling he'd lecture me again about the importance of getting 7 or 8 hours of sleep. (It's a good goal, but I haven't gotten that much sleep since I hit puberty unless I was recovering from surgery and/or anesthesia.) To give my doc credit, Rabins says the best way to maintain cognitive health is to exercise, get more sleep, lower stress and eat a lot of fresh fruit and vegetables. Maybe he reads my doctor's chart notes. Rabins adds that people should do more things they enjoy both socially and intellectually. We should definitely do all of these good things anyway, but life keeps getting in the way.
In the mean time, if you are seriously concerned, there are several nice little short quizzes available. Check out the five quick Alzheimer's tests. (http://www.alzheimersreadingroom.com/p/test-your-memory-for-alzheimers-5-best.html). I would have taken at least one of them myself but I had a lot of other pressing things I needed to do at the time so decided I would do it later. Then I forgot.
Sunday, August 24, 2014
Forbidden Subjects
This past week a family I know made a very tough decision to discontinue aggressive medical intervention for a son/husband/father. He wasn't old. He didn't have multiple chronic diseases. His family had informed themselves with good information about the outcome of his injury, knew what their loved one who could no longer speak for himself would want and then acted accordingly. The selflessness of this choice and the compassion with which it was made inspired me to once again press all my friends, family and residents to have what is often perceived as a very difficult conversation.
The Center for Medicare/Medicaid requires skilled nursing facilities to complete documentation of person's wishes to receive or refuse certain kinds of treatment (tube feedings, cardiopulmonary resuscitation, etc.). We have to ask and complete what is called a POLST form. The problem is that the form is only as good as the conversation that accompanies it. After forty years, I'm pretty sure many people do not fully understand what they may or may not be choosing. I'm also convinced that these forms, which can serve as physician orders and travel with a person to the emergency room or hospital, are reviewed often enough. As many in the health care field know, clinicians may also find it difficult to be candid about probable outcomes and effectiveness of aggressive interventions in cases of multiple disease processes, metastatic cancers and advanced age. It's no secret that 90% of our health care dollars are spent in the last thirty days of life.
Why is our culture so opposed to talking about one of what my grandmother called the only certainties in this life, "death and taxes?" None of us likes to think about the end and no one who loves us likes to think of the world without us. There is a flip side. As I mentioned in my last blog, it's a very small group that get to be healthy until they go to sleep and don't wake up. Talking to my husband this morning, I asked him again what he might want.
"Well, if I knew my time was short, I wouldn't want aggressive medical procedures."
"How about if you had an unanticipated stroke that left you unable to walk, get yourself to the bathroom or swallow?" I asked.
"No, I draw the line at someone having to take me to the bathroom or clean me up."
"What about if you could get around but were in middle or advanced stages of dementia?"
"I wouldn't want that either."
My point with my husband is that it is easy to project what we might want if we know the end is near, but so often, our families are left to figure things out when an unexpected crisis occurs. My husband is in terrific health and jogs several miles a day. He would expect full resuscitation and likely get it if he collapsed out on a run. He also will be 79 on his next birthday. As each year passes, the chances that he will continue to enjoy exceptional well-being diminish. If we don't review his choices periodically, he will also have full measures ten years from now when the outcome might not be what he desires.
Unlike my husband, I already have succumbed to several chronic diseases for which there is treatment but no reversal. Being in health care, I have made my wishes clear to my family for three decades. I've seen how CPR turns out most of the time. As a recent editorial in The Journal of Post-Acute and Long Term Care Medicine states, "The public's impression of the success rate of CPR (and the kind of shape people are in after receiving it), thanks in large part to the entertainment industry's portrayal of it, is wildly optimistic." (K.E. Steinberg, JAMDA, 15 (2014). 455) People who have observed videos of actual CPR being performed-even on a manakin-often change their minds about electing for it.
Unfortunately, some people feel that if they say they don't want us to try to save them after they stop breathing, their heart stops or they can no longer swallow, we won't try to fix anything. That isn't the case. Even if you are declining all the life-prolonging options, we will still prefer to treat those things we can reverse. That gets confusing for families. When my husband's father who was in the late stages of dementia developed a urinary tract infection, we treated it. My mother-in-law was unhappy about this, feeling she had been specific about his wishes. I explained that although this might prolong his life a little, not treating it would make him most uncomfortable, so why not make his remaining time as pleasant as it could be.
There are people that can help you understand what your options are. They can help your family understand. But nothing can take the place of your candid conversations with your kids, your spouse, your closest friends. It will assure that the right decisions honoring your wishes are made when the time comes without terrible stress on those who must make them if you can't. And let's be realistic. As I heard an Englishman say on television years ago, "America is the only country in which people think death is optional." It isn't. Do advanced care planning. You can always change that plan with good information from your doctor and/or your personal preferences. Have those forbidden conversations today.
The Center for Medicare/Medicaid requires skilled nursing facilities to complete documentation of person's wishes to receive or refuse certain kinds of treatment (tube feedings, cardiopulmonary resuscitation, etc.). We have to ask and complete what is called a POLST form. The problem is that the form is only as good as the conversation that accompanies it. After forty years, I'm pretty sure many people do not fully understand what they may or may not be choosing. I'm also convinced that these forms, which can serve as physician orders and travel with a person to the emergency room or hospital, are reviewed often enough. As many in the health care field know, clinicians may also find it difficult to be candid about probable outcomes and effectiveness of aggressive interventions in cases of multiple disease processes, metastatic cancers and advanced age. It's no secret that 90% of our health care dollars are spent in the last thirty days of life.
Why is our culture so opposed to talking about one of what my grandmother called the only certainties in this life, "death and taxes?" None of us likes to think about the end and no one who loves us likes to think of the world without us. There is a flip side. As I mentioned in my last blog, it's a very small group that get to be healthy until they go to sleep and don't wake up. Talking to my husband this morning, I asked him again what he might want.
"Well, if I knew my time was short, I wouldn't want aggressive medical procedures."
"How about if you had an unanticipated stroke that left you unable to walk, get yourself to the bathroom or swallow?" I asked.
"No, I draw the line at someone having to take me to the bathroom or clean me up."
"What about if you could get around but were in middle or advanced stages of dementia?"
"I wouldn't want that either."
My point with my husband is that it is easy to project what we might want if we know the end is near, but so often, our families are left to figure things out when an unexpected crisis occurs. My husband is in terrific health and jogs several miles a day. He would expect full resuscitation and likely get it if he collapsed out on a run. He also will be 79 on his next birthday. As each year passes, the chances that he will continue to enjoy exceptional well-being diminish. If we don't review his choices periodically, he will also have full measures ten years from now when the outcome might not be what he desires.
Unlike my husband, I already have succumbed to several chronic diseases for which there is treatment but no reversal. Being in health care, I have made my wishes clear to my family for three decades. I've seen how CPR turns out most of the time. As a recent editorial in The Journal of Post-Acute and Long Term Care Medicine states, "The public's impression of the success rate of CPR (and the kind of shape people are in after receiving it), thanks in large part to the entertainment industry's portrayal of it, is wildly optimistic." (K.E. Steinberg, JAMDA, 15 (2014). 455) People who have observed videos of actual CPR being performed-even on a manakin-often change their minds about electing for it.
Unfortunately, some people feel that if they say they don't want us to try to save them after they stop breathing, their heart stops or they can no longer swallow, we won't try to fix anything. That isn't the case. Even if you are declining all the life-prolonging options, we will still prefer to treat those things we can reverse. That gets confusing for families. When my husband's father who was in the late stages of dementia developed a urinary tract infection, we treated it. My mother-in-law was unhappy about this, feeling she had been specific about his wishes. I explained that although this might prolong his life a little, not treating it would make him most uncomfortable, so why not make his remaining time as pleasant as it could be.
There are people that can help you understand what your options are. They can help your family understand. But nothing can take the place of your candid conversations with your kids, your spouse, your closest friends. It will assure that the right decisions honoring your wishes are made when the time comes without terrible stress on those who must make them if you can't. And let's be realistic. As I heard an Englishman say on television years ago, "America is the only country in which people think death is optional." It isn't. Do advanced care planning. You can always change that plan with good information from your doctor and/or your personal preferences. Have those forbidden conversations today.
Sunday, August 17, 2014
Do We Really Need Nursing Homes?
The August edition of McKnight's Long Term Care News reports Sen. Tom Harkin (D-IA) unveiled a bill to direct more Medicaid funding to home and community-based health care and away from nursing homes. You might think that considering my job, I'd be against this but I'm all for people being able to be where they want and I've yet to meet anyone who says "I want to be in a nursing home." But if you've ever been in the position of being told you are to be discharged from the hospital in two hours on a Friday afternoon with no one at home to help or medical treatments more complicated than once a day....well, there you are. You are glad we're here or if not glad, a little relieved and hoping it isn't going to be some nightmare of dark halls, bad food and people crying for help all night.
Usually after a day or two of adjusting to the idea and learning our goal is your goal, to get you home as quick as possible, you realize it isn't at all what you feared. Some people even find it less difficult than being in the hospital and certainly more entertaining. Here's the rub. 'Back in the day' as we say, your hospital stay would have been two to three times longer. Nursing homes changed their roles in communities when Medicare encouraged us to provide those extra days you would no longer be having in the hospital because skilled nursing care is less expensive We became facilities that could provide less urgent hospital services at 1/3 the cost. It was and still is a pretty smart way to stretch our tax dollars. The same services at home would be cost prohibitive.
We seniors are not going to let anyone mess with our Medicare, or at least not if we know about it, but Senator Harkin was talking about Medicaid, wasn't he? So that's a whole different matter. Those residents of nursing homes who don't have hundreds of thousands of dollars and/or have needs too complex for families, assisted-living facilities or adult family homes, those people who no longer have assets to divest or incomes to invest--those people should, according to Harkin, get their care at home or at an out-patient clinic.
Remember when we 'deinstitutionalized' the chronically mentally ill, only to learn that they didn't get care at home or at out-patient clinics? They live under bridges. But that's a subject for another time.
This is today and the health care crisis in this country gets ever more terrifying. My advice is borrowed from the poet, Robert Frost, "Provide! Provide!" Frost was not a man to use exclamation points liberally.
It's clear that unless we get informed and politically active, we'd better get serious about maximizing our health.
Usually after a day or two of adjusting to the idea and learning our goal is your goal, to get you home as quick as possible, you realize it isn't at all what you feared. Some people even find it less difficult than being in the hospital and certainly more entertaining. Here's the rub. 'Back in the day' as we say, your hospital stay would have been two to three times longer. Nursing homes changed their roles in communities when Medicare encouraged us to provide those extra days you would no longer be having in the hospital because skilled nursing care is less expensive We became facilities that could provide less urgent hospital services at 1/3 the cost. It was and still is a pretty smart way to stretch our tax dollars. The same services at home would be cost prohibitive.
We seniors are not going to let anyone mess with our Medicare, or at least not if we know about it, but Senator Harkin was talking about Medicaid, wasn't he? So that's a whole different matter. Those residents of nursing homes who don't have hundreds of thousands of dollars and/or have needs too complex for families, assisted-living facilities or adult family homes, those people who no longer have assets to divest or incomes to invest--those people should, according to Harkin, get their care at home or at an out-patient clinic.
Remember when we 'deinstitutionalized' the chronically mentally ill, only to learn that they didn't get care at home or at out-patient clinics? They live under bridges. But that's a subject for another time.
This is today and the health care crisis in this country gets ever more terrifying. My advice is borrowed from the poet, Robert Frost, "Provide! Provide!" Frost was not a man to use exclamation points liberally.
It's clear that unless we get informed and politically active, we'd better get serious about maximizing our health.
- It's not too late to eat better food. Take advice from Michael Pollan, "Eat real food, but not too much." Real food tastes great when it hasn't traveled very far so support your local farmers.
- Work on your balance. A lot of long stays begin with a fall. Strengthen your core. Do some dynamic movement. Try yoga. Studies find dancing is great for balance. And if you can't dance, rock out in your chair. Other researchers found this to be excellent for core strengthening.
- Work on your brain. It gets stiff if you don't challenge it. There are some very senior brain strengthener apps for iPads and other tablets. I'm doing Luminosity every day. I'll let you know if it isn't working.
- Make new friends and keep the old ones. Social support does more than you can imagine in keeping us healthy and independent. If you have trouble finding new friends, come volunteer at the nursing home. You'll have a whole large family before you know it
We can all hope for a day when nursing homes are no longer needed, a day when we live full productive lives into our hundreds and then simply lie down and pass away. At least, that's what I hope for as I navigate my 'golden years.' But diverting more funding away from the services we provide won't be adequate to the costs in tax dollars and, even more importantly, human suffering. It isn't a real solution. It panders to that clear feeling all of us have that, "I don't want to end up there." Keep yourself informed. They are arguing about our future.
Until next time,
Andy
Until next time,
Andy
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