Archive for October, 2011

The Right to Informed End of Life Decisions

 Voluntarily Stopping Eating and Drinking

 If a patient is in need of life-sustaining medical treatment such as dialysis or a ventilator they have a legal right to decline this care.  Suffering or not, this patient can legally choose to end their life.  Other patients nearing the end of life may not have this choice.  They may be suffering, or facing long declines that might be accompanied by severe symptoms including pain, lack of mobility, or growing dementia.   There is no life saving treatment to decline; having said that, there is a choice for these patients, a choice that has produced controversy.   Voluntarily stop eating and drinking (VSED) to accelerate the dying process is a proven evidenced based practice that produces what is labeled a good quality death.  A good quality death by definition is a death with as little pain as possible, on a patient’s own terms, and in a comfortable setting. The question before us becomes, what is the medical profession’s responsibility in this case?  Should patients be informed of all their end of life options, including aggressive treatment, foregoing life sustaining treatment, or VSED?   In the United States, physician assisted death is illegal.  VSED on the other hand is legal in every state since the physician is not assisting death; it is a choice made by the patient. VSED and information regarding this choice, however, is often withheld from patients.  The medical profession fears that it is suicide, illegal, or it is just unsure of the law.

While the idea of dying from hunger and dehydration can seem horrible, VSED is not the same thing. There are studies that show 94 percent of VSED deaths as “good deaths.”  The body naturally releases pain-relieving opioids in times of crisis.  It is believed that this same process can occur during VSED, and patients actually report improvement in their symptoms.  The normal dying process itself often includes discontinuing the consumption of food and liquids in the final days before death.  Palliative care, which is geared at relieving physical and emotional distress despite its inability to cure the affliction, should also be considered.  This can effectively accompany VSED and would insure as much comfort as possible.

Take the case of Armond and Dorothy Rudolph.  A couple both over 90 years old who were facing diminishing health. Mr. Rudolph had spinal stenosis, which causes chronic pain while Ms. Rudolph was losing her mobility; both faced early dementia.  The Rudolph’s believed they had enjoyed a satisfying life to this point and now they were scared of losing their independence.  Their son, Neil Rudolph remembers, “Their great fear was that they [would] end up in a nursing home.”  This fear became true for the Rudolph’s who entered an assisted living residence.  When the slow deterioration of their health seemed inevitable, the Rudolph’s put their plan into action.  They chose to voluntarily stop eating and drinking (VSED) which “hastened their dying” process.  The Rudolph’s, like others who make this choice, did so to avoid a slow decline in health, one likely accompanied by suffering.  By making this choice they took back control of their lives.  They had what they would have perceived to be a “good death.”

A similar positive account is provided in Joshua Segar’s death.  Mr. Segar chose VSED when Parkinson’s disease became a more unmanageable burden for him.  Mr. Segar’s family recounts his death as a weeklong process without pain.  They believe his decision of VSED provided Mr. Segar relief.  They viewed his death as “peaceful and . . . beautiful.”

If you are conflicted or bothered by these stories, you are not alone.  The assisted care home in which the Rudolph’s were living in demanded they leave upon realizing their intentions.  The Rudolph’s were forced to complete their plan in a private home, with the help of their family.   Mr. Rudolph died ten days later and Ms. Rudolph died the following day. In the Rudolph’s case “legal apprehension” is believed to have caused their eviction from the assisted living home.  Some doctor’s would call VSED suicide, viewing VSED as ethically wrong because by definition, suicide is “the act of hastening or causing one’s own death.”  Perhaps what needs to be considered is the way we perceive the act of death: whether it is correct to see death as “harm to the one who dies,” or that death can bring much awaited relief.

There is no clear side in this debate.  What is certain is that we each have values, ethics, spiritual beliefs, and life experiences that would impact our view of VSED.  What should be absolute is that the patient should be made aware and informed of all the possible end of life choices, including VSED. This assures that the patient can make the best-informed decision for themselves and their family.  In California advising the patients of end of life alternatives became law in 2008, removing the physician’s role in identifying what the patient might require. It would seem responsible for the rest of the country to follow this example and empower patients to make their own “informed health care and end of life decisions.”  Laws that allow these decisions to be carried out without legal complications should also be enacted.


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Obesity in Senior America

“Human’s are Designed to Eat”

Jim Keller is a psychologist who helps obese people lose weight.  When beginning a relationship with a client he compassionately assures them that “humans are designed to eat.” Keller demonstrates empathy in understanding that “fat cells do not like to be shrunk.”  He does not deny “personal responsibility” plays a key role in weight management.  He believes mastering the “biology of the machine” that is the human body as the challenge of losing and keeping off weight. Keller concludes our body is a machine we can learn to fuel optimally by mastering “how the human machine works,” and the importance of “(making) this machine feel safe … well-fed, (and) well-hydrated.”

The baby boomer generation should take head to Keller, because baby boomers are in need of addressing the highest incidence of obesity seen in either the generation before or after it.  Obesity is defined through a tool called the Body Mass Index (BMI).  A BMI number is a measure of body fat in a person.  BMI incorporates weight and height into this measurement.  According to current BMI measures seventy-two percent of baby boomers are reported to be overweight, with half—36 percent—regarded as obese.  Comparatively, from either the previous or subsequent generations only 25 percent fall in this category.  This is a cause for alarm.

As a nation we have access to healthier food.   Health care has improved.  Levels of physical activity appear constant from one generation to the next.  The 2004 National Health Interview Survey found senior respondents aged 50 to 64 as identifying themselves with  “good” and “excellent” health in comparison to scores for seniors in the same study done in1994.  These health benefits, healthier food, and overall positive attitudes of health aside, it is clear that obesity in senior America must be addressed.  The main culprit in our society seems to be our increased  consumption of foods higher in fat.  Other risk factors for obesity include  our slowing metabolism once we reach age 40, meaning the same amount of calories now leads to weight gain.  Weakened senses of smell and taste also lead to increase in consumption of foods high in salt and often sugar.  Sugar equals more calories.  Medicines also impact appetite and taste, again creating an increase in consumption of high sugar.  Lifestyle changes, including retirement, death of a partner, or reduced social contacts can lead to loneliness or depression.  Overeating is often a symptom of these feelings.

Obesity alone is not the main danger.  Obesity is not considered a chronic disease.  The complication is that sixty-two percent of Americans 50-64 years of age present one or more obesity related health problems.  These include heart disease, cancer, arthritis, and high-cholesterol.  Obesity also impact levels of activity, and has shown a correlation to higher levels of depression.  Obesity also leads to higher rates of disabled seniors.  Women in their 50’s seem to have the highest incidence of obesity today.  Research by the Mayo Clinic has shown a connection between obesity and Alzheimer’s disease.

The combination of diet and exercise are proven to be the most effective tools to combat obesity.  To keep weight under control the first step is eating well. This includes lowering calorie consumption and improving the intake of nutrient rich foods.  Some suggestions incorporate a high fiber diet, containing whole grain breads; lean proteins like fish should be chosen when possible; calcium rich foods are also needed, these consist of dairy products like milk, but can be found in tofu and broccoli as well; all in addition to an abundance of fruits and vegetables.  With a healthy diet come benefits.  They boost energy, which helps us feel better.  Many also believe they look better, in turn raising self-esteem.  Physiologically our internal structures, including bones and organs are stronger over time.  Our ability to fight disease increases.  There are marked declines in the incidence of strokes, heart disease, high-blood pressure and diabetes.  We see a decline in cancer.  In terms of mental health, nutrients power the brain, and we see a decrease in Alzheimer’s.

Exercise is the next powerful step against obesity.  Simply walking 20-30 minutes a day has been shown to reduce the risk of diabetes by 60 percent and lowering cholesterol. The Mayo Clinic tells us that lack of energy is not “a result of age, but inactivity.”  Exercise returns this energy.  Other benefits are an increase in the efficiency of insulin, preventing or lowering the risk of type II diabetes.  When part of the exercise includes resistance or weight training, the benefits to healthy bone mass reduce the risk of osteoporosis.  More benefits include improved immune systems, and better circulation, and loss of fat which also proves to lower the risk of cancer.

Using Keller’s analogy of the body as a machine, the best weapons to combat obesity appear to be keeping the machine optimally fueled by choosing the right food in addition to exercising to keep the machine in top working condition.




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Depression is Not a Byproduct of Old Age

Understanding and recognizing depression in our elders needs to become a priority.  According to the National Institute of Mental Health (NIHM) “studies show that many older adults who die by suicide — up to 75 percent — visited a physician within a month before death.”  This fact clearly demonstrates the need to better understand depression in older Americans.  NIMH reports that one of the reasons for this is that depression presents itself in conjunction with other severe “illnesses, such as heart disease, stroke, diabetes, cancer, and Parkinson’s disease.”  They conclude that because of this, the public, and health care professionals attribute the depression to a natural part of the aging process.  Depression becomes a secondary symptom.  However, NIHM clearly says, depression is “not a normal part of the aging process.”

The MAYO Clinic defines depression as “a variety of emotional and physical problems. You may have trouble doing normal day-to-day activities, and depression may make you feel as if life isn’t worth living.”  They warn that depression is a “chronic illness” that “requires treatment.”

The Mayo Clinic describes some of the symptoms of depression for older adults, echoing NIMH’s concern that we often ignore these signs and label them the reality of getting old.  They include “fatigue, loss of appetite, sleep problems or loss of interest in sex.”  NIMH says seniors chose to stay home rather than go out.   The American Association of Retired People (AARP) explains the words used by the elderly often minimize signs of depression.  “Older patients come in saying, ‘I can’t sleep, nothing tastes good, or my back hurts.” Expressions of suicide take on a different tone.  An example is how we interpret a senior who proclaims, “If God took me now, I wouldn’t mind.”  NIMH emphasizes awareness of language.  The words “dissatisfied…bored, helpless or worthless,” are cause for alarm.

NIHM believes that the risk for depression in elders rises with illness and with loss of functioning and mobility.  They highlight that major depression in older people in our country ranges from one to five percent, but that it goes up to 13.5 percent for those needing home care and as high as 11.5 percent for those that are hospitalized.  They report an additional five million seniors with identifiable symptoms of depression that fall short of meeting clinical criteria.

The National Alliance on Mental Illness (NAMI), says that depression in seniors is not caused by any one definitive factor.  They tell us that biologically genetics play a role.  With this hereditary predisposition in place, “stress, loss, or major life changes” can trigger depression.  For seniors this includes loss of loved ones, retirement, having to relocate, and losing their role as a caregiver.  Medications can also produce depression.  Substance abuse is another risk factor.   Women are at greater risk, up to “twice as likely” to have depression.  Hormonal changes can be a contributing factor.  Elderly women are more likely to provide care to the ill, a heavy burden.  Unmarried and widowed women share an elevated risk.  Finally NAMI reminds us that conditions like “heart attack, stroke, hip fracture or macular degeneration, and procedures such as bypass surgery are known to be associated with the development of depression.”

Heather Pollett’s literature review in June 2008 for the Canadian Mental Health Association discusses protective factors that insulate seniors from depression.  They include healthy self-esteem, having the ability and “flexibility” to cope with “illness and difficult life events,” as well as healthy social connections.

Suicide Awareness Voices of Education (SAVE) tells us that 90 percent of clinical depression can be treated.  The precursor for this is for the senior to get help.  With professional care the AARP reports that a number of interventions including counseling and medication can be effective.

By educating the public, we can increase the chance help arrives.  NIMH’s pamphlet on depression lists valuable steps that can help a senior with symptoms of depression.  The first step should be to visit a primary care provider or a mental health professional.  Depression requires professional care.   NIHM encourages “support, understanding patience and encouragement.”  They urge one to talk about the problem with the senior, and just as importantly to listen.  Comments about suicide should be taken seriously and reported to professional health care workers.  NIHM also advocate that we help the person get out for walks and other activities.  Helping the person remember that the treatment they may be undergoing does work is also valuable.  Remember, as NIHM says, depression is “not a normal part of the aging process.

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