News and Narratives of Interest – 2014

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When my 85-year old father took himself off dialysis and decided his multiple advanced terminal illnesses were sending him a message, his elite teaching hospital sent us to a large hospice organization in the region. Almost immediately we realized we were getting stock answers to our questions, and began to question whether our father, and our family, would get personalized care. We contacted a smaller hospice organization that saw us through the weeks ahead with compassion and care.

A recent “New Old Age” blog by Paula Span reminded me of a difficult question many of us have to face—and provided some guidance, if not quite answers. “How to Choose a Hospice” is the question at hand; and interviewee Naomi Naierman, founding president and CEO of the American Hospice Foundation (closing for lack of funding), has some important suggestions. Families and patients should know that in most localities there is a choice among hospices. Hospice care is no longer always delivered by local non-profit organizations: More often hospices are run by large for profit corporations—and not all hospices put the patient and family before the bottom line. This interview with Naierman offers great questions to ask of hospices and even more are included in Naierman’s guide, “Choosing a Hospice: 16 Questions to Ask.”

One question we did not see on this list is the “bounce” question. Paula Span herself, in her New Old Age blog post this winter, reported that from one-fifth to one-third of patients are discharged alive from hospice each year—and the number is rising. Yes, one-third of those discharged are patient decisions to leave; but two-thirds are hospice decisions. If a patient is not losing ground—if the illness is not getting worse, even if the patient’s health is not improving, the patient can, and should, according to Medicare regulations, be discharged. This is a sad irony given evidence that patients in hospice care often do better than those without hospice care. And all caregivers know that patients at the end of life have a varied course of illness progression—sometimes improving and sometimes declining.  Hospices can monitor a patient’s illness course in many different ways, and it is likely, that some hospices are readier to “bounce” than others. It would be well to ask a hospice, “What is your rate of hospice initiated discharge?”

Naierman and her colleagues at the American Hospice Foundation understand that we all need help in formulating the questions that will best elicit information we need. This is especially true if we are trying to have a difficult conversation, to really understand someone else’s experience, beliefs, and preferences. Physician and medical anthropologist Arthur Kleinman recognized this in 1978 when he formulated his now classic eight (8) questions that would help clinicians understand illness from the cultural perspective of the patient. Now Atul Gawande, surgeon and writer, has formulated a question-based guide for doctors who find it difficult to have conversations with patients who are experiencing illness that could possibly result in death within the next year. The Ariadne Labs project is now training physicians in order to test the effectiveness of this approach. We hope these questions prove an effective way for reluctant physicians to have these important end-of-life conversations with patients and families. They may, if turned around, be a way for patients to approach the conversation with physicians. They are not yet published, but we will keep you posted.

Meanwhile, as physicians struggle to have conversations about death and dying with patients, it seems that patients, families, caregivers—and everyone else—are having these conversations without them, connecting with each other, in every way possible. When NPR host Scott Simon tweeted from a week-long bedside vigil with his dying mother, well over one million people followed his tweets, and The New Yorker, The Huffington Post, and The Atlantic all wrote articles about “tweeting death.” Social media, the ultimate distancing through virtual intimacy, has captured our cultural shift toward knowing death and dying, toward connecting with the end of life, our own and others.

And to end this eclectic review of what is new and of interest, let’s turn to a perfect medium for ending, a graphic novel by The New Yorker cartoonist Roz Chast. Can’t We Talk about Something More Pleasant is Chast’s book-length comic about the last years of her parents’ lives. You may have read the excerpt in The New Yorker last winter. If so, you know you are in for a real treat. Gentle humor, sharp insight, real Brooklyn dialogue, and great drawings keep us smiling and nodding even as we recognize the complexity of caregiving, the struggle of the fiercely independent elderly to maintain their independence, and the simple sadness of losing parents at any time of life. Enjoy!


A PDF copy of this post:  News and Narratives of Interest-Summer 2014