History > 2009 > USA > The elderly (I)

When You’re Your Mother’s Keeper

NYT

23.8.2009

http://www.nytimes.com/2009/08/23/fashion/23genb.html

Suburbs See a Challenge

as Residents Grow Older

December 6, 2009
The New York Times
By LIZETTE ALVAREZ

HAMILTON, N.J.

THE trash talk on the boccie court at the Hamilton Township Senior Center was heating up.

“What’s the matter, you can’t bend down?” Natale Gigliotti, 71, shouted to an opposing player who lunged as he tossed the ball. “Corto, corto” — short, short — Mr. Gigliotti said as the ball landed. “That’s a boo-boo.”

“Ohhhh, they love to talk,” said Ray Fink, 79, Mr. Gigliotti’s boccie partner and a regular at the center’s billiard tables and boccie court.

Hamilton, in Mercer County, is a pleasant suburban town, not far from Trenton, with a smattering of historic homes, the requisite big-box stores and a pre-Revolutionary pedigree. It also has more residents who are 65 and older than many other towns in New Jersey — 15 percent of its nearly 94,000 people, while in some towns the proportion is 5 percent or less — and that demographic fact has forced Hamilton to pay close attention to the needs of its elderly.

This is not to say that other towns and counties are far behind.

In just two years, baby boomers will start to retire, and by 2030 the number of America’s elderly is expected to reach 72 million, more than double the number in 2000. Demographers expect the suburbs to age particularly quickly, as residents retire close to home, or as those who have already moved to the Sun Belt return to live near relatives as they grow frail.

Some towns are already feeling these effects: Twenty percent of Glen Cove, in Nassau County, is 65 and older, for instance, as is 23 percent of Somers, in Westchester County.

This increase in the number of elderly will place unparalleled strains on many suburbs’ services.

“In the Northeast, we have to look at it as if the clock is ticking,” said Brian M. Hughes, the Mercer County executive. “We have an aging housing stock and a population that is not increasing as much as the rest of the country. We need to figure out how we’re going to provide more services with a smaller tax base.”

Mercer County, with its grayer population, offers a peek at the future in terms of preparing for its aging residents.

On the housing front, the county has seen a sharp rise in developments for people 55 and over. These adult communities, some with house prices reaching $500,000, pay homage to the retirement villages of Florida, only on a smaller scale. They offer gardens, large clubhouses and swimming pools, games and a built-in social life.

An estimated 13 such adult communities have been built in Mercer County since 2002 — a much brisker pace than in previous years. Almost all their homes, usually one story and requiring little yardwork, are tailor-made for the aging.

The county has also seen a boom in assisted-living facilities, said Sherrill Senter, a real estate agent with the Keller Williams Hamilton firm, who added that builders are planning for older people even in the general housing market. Many newer houses, she says, have a bedroom on the first floor or a study that can easily be converted into a bedroom for an aging parent.

Real estate agents, eager to learn of plans that will affect them, now attend meetings between nonprofit groups and the Mercer County Office on Aging.

The county has also supplemented its network of shuttle vans for the elderly by arranging to use other vans, borrowed from the Association of Retarded Citizens and other groups, when available. And the Hamilton senior center is offering its own transportation service — something such centers do not often do.

“As the population ages, we have to find a way to get them mobile,” said Kathleen Fitzgerald, a nurse and the supervisor of senior services at the center.

Last year, also with its eye on a grayer future, Mercer Community College started to offer a certificate in gerontology for health care providers, social workers, caregivers and others. The required courses include such subjects as the aging process, memory loss and a holistic approach to aging.

Eileen Doremus, executive director of the county’s Office on Aging, said that a gerontology certificate would become essential to doing business. “It doesn’t matter what realm you work in and live in,” she said. “You will be interacting with people who are older, be it in real estate, health care, retail.”

Local governments like Mercer County are not alone in their efforts. Over the past two years, the state of New Jersey has instructed 400 chronic disease health managers in training the elderly to avoid costly trips to hospitals. Trainers teach the elderly how to keep tabs on their ailments and cope with pain and frustration.

Senior centers are another important aspect of elderly care, and so it is in Mercer County. As he took a break from one of his regular billiards games, Mr. Fink — Mr. Gigliotti’s boccie partner — explained how he ended up at the Hamilton senior center.

“I didn’t want to move into the city; I have always lived in the suburbs,” said Mr. Fink, a former quality control manager for an electronics manufacturer. He also wanted to be near his son, who lived in Hamilton. Then, he said, “I met a couple who told me about Mercer County and said they had the best senior center. I’m very active.”

The senior center moved to a spacious building in 2001. To be successful, such facilities must shake off their stigma as depressing places where the elderly come just to eat a hot meal and shuffle about. In Hamilton, that stigma remains, but less so every year, Ms. Fitzgerald said.

The center, which is publicly financed and has a hard-to-get national certification by the National Council on Aging, provides the requisite lunch, health checks and help with paperwork. But visitors can also sit down at computer banks to learn how to design Web pages or post photos online; they do the cha-cha with a dance instructor; sing in choral groups and on karaoke night; swim in the small pool; smack down dominoes and stage plays.

There are even a few younger patrons, whose needs differ from those of older ones. One example is Paula and Jack Beiger, who practiced the rumba one morning, keeping impeccable time to the music.

“Some people our age are almost embarrassed to come to the senior center,” said Ms. Beiger, 54, who is allowed in only with her 63-year-old husband (members must live in Hamilton and be at least 60). “We come just for the dancing and have such a good time.”

As for Mr. Fink, he does not plan to leave Hamilton Township. But he does worry about the aging of the baby boomers. He waited a year and a half for his current apartment — in a subsidized building for the elderly called Pond Run — and that was before the rising tide.

“As a nation, we have to set up more volunteer programs to support these people,” Mr. Fink said. “There will be so many of them.”

Suburbs See a Challenge as Residents Grow Older; NYT, 6.12.1009, http://www.nytimes.com/2009/12/06/nyregion/06old.html

Helping the Aged

Leave Nursing Homes

for a Home

September 19, 2009
The New York Times
By JOHN LELAND

PHILADELPHIA — Walter Brown never wanted to live in a nursing home, but when he had a stroke two years ago, he saw little choice. Mr. Brown, 72, could not walk, use his left arm or transfer himself into his wheelchair.

“It was like being in jail,” Mr. Brown said on a recent afternoon. “In the nursing home you’ve got to do what they say when they say it, go to bed when they tell you, eat what they want you to eat. The food was terrible.”

But recently state workers helped Mr. Brown find a two-bedroom apartment in public housing here, which he shares with his daughter. “It just makes me more relaxed, more confident in myself,” he said, speaking with some difficulty, but with a broad smile. “More confident in the future.”

A growing number of states are reaching out to people like Mr. Brown, who have been in nursing homes for more than six months, aiming to disprove the notion that once people have settled into a nursing home, they will be there forever. Since 2007, Medicaid has teamed up with 29 states to finance such programs, enabling the low-income elderly and people with disabilities to receive many services in their own homes.

The program in Pennsylvania provides up to $4,000 in moving expenses, including a furniture allowance and modifications to the apartment, and Mr. Brown has a home health aide every morning and a care manager to arrange for services like physical therapy. The new programs, financed largely by $1.75 billion from Medicaid, are a sharp departure from past practices, where Medicaid practically steered people into nursing homes.

“Medicaid has had an institutional bias in favor of nursing homes,” even for people who do not need them, said Gene Coffey, a staff lawyer at the nonprofit National Senior Citizens Law Center. “Federal law requires states to provide nursing home services. They don’t have to provide home or community-based services.”

For Mr. Brown, the transition to his own home has changed his life, he said. Now, with his motorized wheelchair, he travels the city on public buses, visiting friends in other neighborhoods.

“It’s a great feeling,” he said. “In the nursing home I got up at 5 o’clock in the morning, then the rest of the day was just watching the TV or my VCR. I wanted to be able to get out and see people, see the world. I didn’t want to be confined. Now I go where I want to go.”

States and the federal government hope to save money, though research about cost savings has so far been inconclusive. A recent study by researchers at the University of California, San Francisco, found that home care costs taxpayers $44,000 a year less than a nursing home stay — though this number cannot be used to estimate total savings, because often home-based services replace family care, not nursing home care.

About 1.5 million Americans are living in nursing homes.

“It’s amazing how quickly people can end up in a nursing home,” said Jean Janik, the director of community living options at the nonprofit Philadelphia Corporation for Aging. “Say you’re a single man and have a stroke, and need to go into a nursing home to rehab. You’re elderly so you don’t quite bounce back quickly. After 60 days, Medicare doesn’t pay any longer, so you need a Medicaid grant to stay in the nursing home. Then your Social Security will go to the nursing home.”

Many lose their apartments and regular support from family members, Ms. Janik said.

“We meet people who say, ‘I went to the hospital and next thing I know, here I am. I don’t know what happened to my apartment.’ ” Ms. Janik added, “We go and check, and it’s not in their name. Especially if they don’t have a strong family support system in place. A lot of people just think, Uncle Joe fell and broke his hip and now he’s in a nursing home, so be it, that’s where he’ll be. People don’t realize they can get services in their home.”

Each participating state has designed its own program, called Money Follows the Person. The federal government, which shares Medicaid costs, provides extra financing for the first year.

Some experts worry that the programs will end up transferring some of the expenses of caring for the elderly or the disabled to their family members.

Carol Irvin, a senior researcher at Mathematica Policy Research has been contracted by Medicare and Medicaid Services to study the costs of the program in its first five years.

“It could be shifting costs onto a person’s relatives,” Ms. Irvin said. “But even if it’s not saving money, a lot of people believe living in the community is the right thing for individuals.”

Elizabeth Kamara, 72, spent 18 months in a nursing home after having her left foot amputated because of diabetes. Mrs. Kamara can get around using a walker, but in the nursing home she spent whole days in a wheelchair.

“I just let people do things for me,” she said. “They say, ‘If you fall, we’ll get in trouble. Please sit down.’ ”

Mrs. Kamara has moved into a independent living facility, where she cooks dishes from her native Sierra Leone and navigates the hallways on her own. She gives herself insulin injections and gets a friend to drive her to doctors’ appointments. An aide comes twice a week to help clean. “This is my home; I’m free,” she said. “In the nursing home it was two persons in one room. Here I have my privacy. I can get my hair done, my nails done.”

Susan C. Reinhard, a senior vice president of the AARP Public Policy Institute, said of Money Follows the Person: “It’s gotten Congress’s attention, and shown that people can leave a nursing home. That is a wake-up.”

For Esther Pinckney, 88, who ended up in a nursing home after a stroke, moving out has been literally a breath of fresh air. Ms. Pinckney now lives in a bright subsidized apartment where home aides visit twice a day.

“What didn’t I like about the nursing home?” she asked recently. “What would you like about smell, smell, smell, morning, noon and night?”

Because Ms. Pinckney lost her apartment and furniture while she was in the nursing home, the Philadelphia Corporation for Aging bought her new furniture and a microwave oven. Before, she said, her Social Security check went to the nursing home; now she pays 30 percent of her check for her rent. “I couldn’t even buy a soda,” Ms. Pinckney said. “You want to be independent, don’t you? That’s what I wanted.”

Life on her own has not been perfect, she admitted. Aides often fail to show up or spend their time talking on the telephone.

But her pastor takes her to church four times a week, and she can go to stores near her building. If her health should fail again, she said, she did not like to think about going back into a nursing home.

“Don’t mention it,” she said, her face tightening. “I don’t want to do that.”

    Helping the Aged Leave Nursing Homes for a Home, NYT, 19.9.2009, http://www.nytimes.com/2009/09/19/health/policy/19aging.html

Experiencing Life, Briefly, Inside a Nursing Home

August 24, 2009
The New York Times
By KATIE ZEZIMA

MAMARONECK, N.Y. — For 10 days in June, Kristen Murphy chose to live somewhere she and many others fear: a nursing home.

Ms. Murphy, who is in perfect health, had to learn the best way to navigate a wheelchair around her small room, endure the humiliation that comes with being helped in the bathroom, try to sleep through night checks and become attuned to the emotions of her fellow residents.

And Ms. Murphy, 38, had to explain to friends, family and fellow patients why she was there.

Ms. Murphy, a medical student at the University of New England in Biddeford, Me., who is interested in geriatric medicine, came to New York for a novel program that allowed her to experience life as a nursing home patient.

Students are given a “diagnosis” of an ailment and expected to live as someone with the condition does. They keep a daily journal chronicling their experiences and, in most cases, debunking their preconceived notions.

The program started in 2005 after a student approached Dr. Marilyn Gugliucci, the director of geriatrics education at the medical school. “ ‘Dr. G,’ ” she recalled the student saying, “ ‘I would like to learn how to speak with institutionalized elders.’ What came out of my mouth was, ‘Will you live in a nursing home for two weeks?’ ”

To Dr. Gugliucci’s surprise, she found nursing homes in the region that were willing to participate and students who were willing to volunteer. No money is exchanged between the school and nursing homes, and the homes agree to treat students like regular patients.

“My motivation is really to have somebody from the inside tell us what it’s like to be a resident,” said Rita Morgan, administrator of the Sarah Neuman Center for Healthcare and Rehabilitation here, one of the four campuses of Jewish Home Lifecare.

“But she is really there to study herself, her own feelings about living in a nursing home,” Ms. Morgan added, referring to Ms. Murphy.

Geriatric specialists hope the program and others like it help generate interest in the profession, one of the most underrepresented fields in medicine. Medical schools and residencies require little to no geriatric training, and many students are reluctant to get into the field because it is among the lowest paid in medicine.

In 2005, there was one geriatrician for every 5,000 people over 65, according to the American Geriatrics Society; by 2030 that ratio is expected to increase to one for every 8,000 patients. Geriatricians must participate in a two-year fellowship program after medical school to become certified. In 2007, only 253 of 400 fellowship slots were filled, and only 91 of the physicians graduated from medical school in the United States.

“It’s kind of a crisis,” said Dr. Cheryl Phillips, president of the society. “I don’t think many seniors recognize this.”

Like many medical students, Ms. Murphy was scared of nursing homes. The feeling began when, as a young adult, she visited her grandmother, who had Alzheimer’s disease.

“I think nursing homes are scary,” she said, “but I don’t think you can be a good doctor if you’re scared of the place where a lot of your patients live.”

The first few days, which included filling out paperwork, undergoing a full-body mole and sore check, eating pureed foods and being raised out of bed with a lift, did nothing to validate her decision. When she wedged her wheelchair into a corner and could not get out, she cried in frustration.

“All I wanted to do was shut my door and stay in here,” said Ms. Murphy, whose “diagnosis” was a mild stroke that affected her right side, difficulty swallowing and chronic lung disease. “But I understood I had to go out.”

Not everyone does. Some patients want to talk for hours, while others act out, like a woman who pinched Ms. Murphy as hard as she could. Many sit in the hallway by the nurse’s station each day because it is a hub of activity. Emotions run high.

Ms. Murphy said she soon learned that many patients cried because they knew that they would most likely never live anywhere else, or because they missed family and their old life.

“At times I felt really lonely and got depressed,” she said. “Sometimes it was an emotional roller coaster, up and down, up and down.”

No one said a word the first time Ms. Murphy showed up at the daily bingo game. She started to talk to anyone who would listen. And she was surprised what happened.

First she bonded with Camille Stanley, the “queen bee” of the social scene. Then she found Dr. Thomas N. Silverberg, 89, a former internist and arthritis specialist with advanced rheumatoid arthritis. “My specialty is slowly killing me,” Dr. Silverberg said.

The two talked for hours about life and medicine. Unlike the friendships she makes as an adult, slowly nurtured over dinners and drinks, bonds in a nursing home, where there is nothing to do but talk, are forged quickly and deeply.

“When I came in, I was worried about working with older folks because I was afraid I wouldn’t be good at it,” Ms. Murphy said. “Now, if anything, I’m worried I’ll love them too much and it will really hurt to work with folks at the end of their lives.”

Most residents knew why she was there. During her going-away party they presented her with a big card, and shouts of “We love Kristen” were heard throughout.

The program has solidified Ms. Murphy’s desire to work with older people. And the hardest lesson she learned — that for some people, it is better to be in a wheelchair or to have limited mobility — will make her become a better doctor, she said.

“As a doctor, my job is to help patients live the life they want to,” she said. “And if they’re in pain, you have to say ‘That’s O.K. if you want to spend your time in a wheelchair.’

“For me that’s such a different place to be. Because I hate this chair. It still startles me that that’s the choice.”

Ms. Murphy said the care she received at the home was outstanding. But there were things that could use improvement: she did not realize she could ask for things like soda, and she felt that shower bars were too high for someone in a wheelchair. She also told the staff at a debriefing session that families should be included in more activities.

Dr. Phillips of the American Geriatrics Society, which is not involved with this program, said the challenge was to see “how this replicates everywhere else and how enthusiastic medical students are to take this on.”

Another of the 10 students who have gone through the program, William Vogt, spent 10 days last summer in a nursing home at the Veterans Affairs hospital in Augusta, Me. Mr. Vogt, who spent a day wheeling around with petroleum jelly smeared on his glasses and cotton stuck in his ears, said he was particularly struck by the fact that many patients considered the nursing home to be home and the staff “a second family.”

Mr. Vogt said the little things counted, like lowering nameplates so patients could locate their rooms and not putting a remote on top of a television, out of reach.

“There’s a little part of it that works its way into everything I do, from patient interaction and awareness of how I come across to what I say,” said Mr. Vogt, a medical student doing clinical work at a hospital in Watertown, N.Y. “There’s this shift of the humanity of it.”

    Experiencing Life, Briefly, Inside a Nursing Home, NYT, 24.8.2009, http://www.nytimes.com/2009/08/24/health/24nursing.html

Generation B

When You’re Your Mother’s Keeper

August 23, 2009
The New York Times
By MICHAEL WINERIP

UPPER SADDLE RIVER, N.J.

WHEN Suzanne Cooper’s elderly mother moved in three years ago, her Alzheimer’s was in an early stage. The 84-year-old was still fairly lucid, so Mrs. Cooper could leave her home, while picking up her son, Griffin, from nursery school or going food shopping.

But in time, the mother turned more inward, having long conversations with herself at the kitchen table or just staring. “She goes into the other world and you try to pull her back, but it gets harder,” Mrs. Cooper said. She would come home with Griffin, 5, and find her mother sitting by the back door holding her blanket and looking lost.

Soon, the 49-year-old Mrs. Cooper couldn’t leave her alone and the days became logistical brainteasers, as she tried to balance the needs of her son and those of her mother.

If she had errands, it could take three hours to get her mother fed, groomed, bathed, dressed and out the door. “Mom can still brush her teeth,” Mrs. Cooper said, “but I have to put the toothpaste on the brush.”

“In fall and spring I could take her on errands and she was content to sit in the car,” Mrs. Cooper said. “There’s no law against leaving an 84-year-old woman in the car with the windows down. But summer and winter, I can’t do that — I’m tied to the house.”

Mother and daughter were sitting on the back deck recently, when Mrs. Cooper jumped up and said, “I need to check on Griffin.” He was supposed to be playing a computer reading game inside. “Sometimes, he finds his way onto the Internet,” she said. “I’ll be back.” Her day is all back and forth: Comfort her mother, mumbling and sobbing at the kitchen table; stop Griffin from biting the sofa cushions.

While she was inside, her mother, Irma Stitz, a retired nurse, carried on a conversation with herself: “God bless you, but you know that. There will be a tomorrow. Yes, because of your hate, hate, hate.”

When Mrs. Cooper returned, her mother said, “The people all may be changing.”

“Mom, can I get you to come in the house and have some soup?” said Mrs. Cooper, moving to help her up.

Mrs. Stitz shooed her away. “I can do it myself,” she said, and she walked into the kitchen and ate her soup.

Mrs. Cooper’s mantra had been, “I want to be a stay-at-home mom, and a stay-at-home daughter,” though for a long time she worried she did neither well. She spent 20 years building a career, rising to become a corporate vice president, and was finally ready to be home. Married late, at 43, to Peter Cooper, an architect, she felt blessed to become pregnant right away. Mr. Cooper was also caring for his parents — now deceased.

They loved this about each other. “Family loyalty,” Mr. Cooper, 55, said. “Other women said, ‘Oh, he’s never married, caring for his parents.’ Suzanne found that appealing.” About 20 percent of baby boomers — 14 million — take care of an aging loved one, according to a Natural Marketing Institute report done for the AARP, and as the Coopers know, it can be a struggle.

Mrs. Cooper was determined not to put her mother in a nursing home. “I don’t want someone else to be there when Griffin scrapes his knees and I felt the same about my mother as she comes to the end.”

“I was sure I could do this myself,” she said. The remodeled house — on a cul-de-sac in an upscale suburb — provides Mrs. Stitz with her own bedroom, bathroom, laundry room and living room.

A widow for 30 years, she had been independent, hard-working and proud, taking care of herself in her Pennsylvania home. It was a long time before the daughter realized the mother had been masking the disease. If the mother came for a visit, she would leave the next morning, before anyone could notice lapses. During one stretch, she and her dog repeatedly had the stomach flu; Mrs. Cooper figured out they were eating spoiled meat. When Mrs. Cooper made stuffed artichokes, a favorite family dish, her mother couldn’t remember how to eat one.

Mrs. Cooper loved her mother’s sense of wonder and her laugh, but this last year, the joy kept contracting. They used to go to the beauty parlor together, but the other day, Mrs. Cooper couldn’t get her mother to their appointment. “Where are we going?” Mrs. Stitz asked. “How will we get there?” She sat back and closed her eyes.

“That’s when I back off,” Mrs. Cooper said.

The less the mother would do, the less the family could do.

“We became increasingly isolated, it was unbearable,” Mr. Cooper said. Nor did the economy help; Mr. Cooper’s firm went from three employees to one. He worked long days and often had night meetings.

The Coopers — attracted by a shared commitment to their elderly parents — began seeing a marriage counselor. “My husband tolerates an awful lot,” Mrs. Cooper said, “but he was worn down.”

She had trouble hiring help; they live three miles from a bus stop. When her mother had heart problems, a home health aide came, but it wasn’t much relief. The mother always took baths; the aide was only supposed to give showers. “If Mom refused to take a shower, the aide wouldn’t come back,” Mrs. Cooper said. “So I gave her a bath before.”

“I kept making phone calls,” Mrs. Cooper said. “There were pages and pages of options. Home aides, nursing facilities — some insisted you have $125,000 before they’d talk to you.”

In June, Mrs. Cooper finally pressed the right button. She found Nancy Bortinger, a geriatric social worker for 33 years. Mrs. Bortinger — who works for Vantage Health System, a local nonprofit agency, and advises parentgiving.com, a Web site aimed at people caring for elderly parents — interviewed Mrs. Cooper for three hours and a few days later made a home visit.

“Suzanne was stuck seeing this in black and white — put Mom in a nursing facility or keep her home,” Mrs. Bortinger said. “We needed to get her unstuck fast, before the family and marriage had a crisis.”

Mrs. Bortinger suggested an Alzheimer’s respite program, where the mother could spend an occasional day, and Mrs. Cooper could get a break. It still took three hours getting Mrs. Stitz out the door. When she resisted, Mr. Cooper suggested to her that as a nurse, she would be able to help with the patients there, and Mrs. Stitz agreed.

Mrs. Cooper savored the day alone with Griffin. Mr. Cooper noticed. “Suzanne’s mood improved enormously, knowing she has choices,” he said. “She gets a break, but doesn’t feel she’s shirked her responsibility.”

Two weeks ago, the Coopers took the next step. They signed up Mrs. Stitz for a week of respite, so they could go on vacation to New England. While not covered by insurance, the cost was manageable — $190 a day. When Mrs. Stitz resisted, Mr. Cooper was able to summon a lucid moment. “Irma, we’re going to take a few days to see my family, you don’t mind?” he said.

“By all means, Peter,” she said.

Mrs. Cooper spent the week before with a Sharpie marker, labeling clothes as if her mother were going off to camp.

The first few days, Mrs. Stitz’s stay was shaky; her doctor was on vacation and there was a mix-up with her medications. But after that, things went smoothly.

The Coopers were supposed to pick her up last Sunday, but the traffic back from Boston was horrible. When Mrs. Cooper called to say they’d be late, a supervisor suggested that instead of rushing, she could let her mother stay one more night, and Mrs. Cooper agreed it was a good idea.

    When You’re Your Mother’s Keeper, NYT, 23.8.2009, http://www.nytimes.com/2009/08/23/fashion/23genb.html

Letters

Health Care for the Old, and the Young

August 23, 2009
The New York Times

To the Editor:

Re “Health Care’s Generation Gap,” by Richard Dooling (Op-Ed, Aug. 17):

While I wholeheartedly agree that overtreatment in the United States has reached epidemic proportions, pitting health care for older adults against care for children is a mistake. Age should not be a marker of a less valuable life. Many people continue to live with a high quality of life well into their later years.

Mr. Dooling’s revelations of high-cost intensive care should instead point us toward better financing for home care, hospice and palliative care programs that provide all patients with treatment that is person-centered and cost-saving.

And, really, shouldn’t everyone have access to preventive care? Whether we are putting programs into place to reduce falls, or financing pediatric immunization, preventive health can be beneficial at every age.

Health care financing should be aimed toward evidence-based, cost-effective programs, not simply at those deemed most “deserving.”

Amanda Hunsaker
Pittsburgh, Aug. 18, 2009

The writer is a doctoral student in the School of Social Work at the University of Pittsburgh.

•

To the Editor:

I commend Richard Dooling for having the courage to utter the unspeakable truth: Despite our vast medical/technological hubris, we cannot cheat death, and shame on those who cling to the belief that we can. Shame also on the many readers who will inevitably excoriate Mr. Dooling for a perceived lack of compassion for the elderly, and the self-interested politicians who will foolishly accuse him of supporting “death panels.”

The fact is that old people eventually die; they are supposed to. Yet the medical establishment makes huge profits peddling the notion that the end of life can be delayed indefinitely. Economics aside, this is inhumane.

We must somehow conjure the common sense to allow people to die with dignity, without suffering, and at the reasonable time when their bodies give up even if their families refuse to do so.

Lisa Wesel
Bowdoinham, Me., Aug. 17, 2009

•

To the Editor:

After reading Richard Dooling’s Op-Ed article, I made my usual morning rounds on my patients. They are — almost to a person — exactly the kind of people who the author feels do not deserve the advanced health care that I am privileged to provide them.

It saddens me to know that my octogenarian — and yes, even nonagenarian — patients, who have paid a lifetime of taxes, fought for their country, live independently and often even still work — have raised the generation that now, increasingly, seems to feel that the surgeries I routinely perform that save lives and enhance their quality are wasteful expenses that our selfish society cannot afford.

Albert C. DiMeo
Fairfield, Conn., Aug.

18, 2009

The writer is a doctor and the director of minimally invasive cardiac surgery at St. Vincent’s Medical Center in Bridgeport, Conn.

•

To the Editor:

In 2006, I learned that I had myeloma, a bone-marrow cancer that is treatable but at present not curable. I am 68 and have led a most satisfying life, but myeloma will most likely shorten that life.

The treatment I have received has been very expensive, but it has kept me robust, and I am thankful. But Richard Dooling’s Op-Ed article is enlightened: if the quality of my life makes me no longer want to live, I want someone to pull the plug on me; I do not want my misery prolonged by any treatment, particularly “insanely expensive procedures.”

I hope that then, I, or someone I designate, will insist on my wishes now: don’t keep me alive for misguided reasons; let me die for enlightened ones. And spend the money thus saved on preventive medicine, making it more likely that younger folks will live long and satisfying lives of their own.

Peter Greer
Exeter, N.H., Aug. 18, 2009

•

To the Editor:

As an ageless, 40-something woman who cares equally about people of all ages, I must object to Richard Dooling’s suggestion to cut “some of the money spent on exorbitant intensive-care medicine for dying, elderly people and redirect it to pediatricians and obstetricians offering preventive care for children and mothers.”

He may not be, as he states, “talking about euthanasia.” But his suggestion reflects the unloving philosophy of ageism that so many elderly encounter daily. Our elders have just as much right as any to life, liberty and the pursuit of happiness, as they see fit and to their very last breath, however and whenever that occurs.

Helena Babington Guiles
San Francisco, Aug. 17, 2009

•

To the Editor:

Richard Dooling’s Op-Ed article is both timely and accurate. It points up the importance of advance directives, so disparagingly and wrongly referred to as “pulling the plug on Grandma.”

I’m a 73-year-old grandma. As is the case with many elderly people, my fear of hospitals is directly related to the fear of being put in some sort of time warp of machine-generated life support, tortured with tubes and left to rot in an undignified and helpless state with no hope of recovery, a heartbreaking burden to my children.

The conversation about end-of-life care should be held in all families. Everyone should provide his or her family, as well as family physician, with a health care proxy and a living will. A lawyer who can help put on paper the necessary directives to conform with the person’s wishes and with the law is helpful, but not required.

Grandmas of the world, take the responsibility for your own end-of-life care now. Tell your families what you want and put it in writing.

Adele Welty
Flushing, Queens, Aug. 17, 2009

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To the Editor:

I’m an elderly person, have worked professionally in care of the elderly, and have helped and visited several friends and relatives at the end of their lives.

I wish Richard Dooling had not expressed the problem in terms of generational conflict, but his statements about end-of-life medicine are accurate and trenchant. If people have enough money, they can (and will, unless they have well-expressed medical directives) buy themselves prolonged and excruciating deaths. That is the main reason for reconsidering what we’re doing now, not an analysis of what else could be done with the money.

Anne Watson
Friday Harbor, Wash., Aug. 17, 2009

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To the Editor:

Richard Dooling writes that we are “incurring enormous debt to pay for bypass surgery and titanium-knee replacements for octogenarians and nonagenarians” and suggests that the money be spent elsewhere.

I will be 82 in several months and have had bypass surgery and a hip replacement. Any time Mr. Dooling would like, I will race him swimming, bicycling or kayaking. I would race him running also, but my orthopedist says I mustn’t run. I further suggest that Mr. Dooling bring along an oxygen tank and a well-fitting mask for his own post-race use.

Paul R. Packer
New Rochelle, N.Y., Aug. 17, 2009

The writer is a doctor.

    Health Care for the Old, and the Young, NYT, 23.8.2009, http://www.nytimes.com/2009/08/23/opinion/l23gap.html

Op-Ed Contributor

Health Care’s Generation Gap

August 17, 2009
The New York Times
By RICHARD DOOLING

IN the 1980s, I worked as a respiratory therapist in intensive-care units in the Midwest, taking care of elderly, dying patients on ventilators. I remember marveling, along with the young doctors and nurses I worked with, over how many millions of dollars were spent performing insanely expensive procedures, scans and tests on patients who would never regain consciousness or leave the hospital.

When the insurance ran out, or Medicare stopped paying, patients and their families gave the hospital liens on their homes to pay for this care. Families spent their entire savings so Grandma could make yet another trip to the surgical suite on the slim-to-none chance that bypass surgery, a thoracotomy, an endoscopy or kidney dialysis might get her off the ventilator and out of the hospital in time for her 88th birthday.

That was back in the mid-’80s, when the nation was spending around 8 percent of its gross domestic product on health care. I and other health care workers solemnly agreed that the spending spree could not continue. Taxpayers and insurance companies would eventually revolt and refuse to pay for such end-of-life care. Somebody would surely expose the ruse for what it was: an enormous transfer of wealth based on the pretense that getting old and dying is a medical emergency requiring high-tech intensive-care intervention and armies of specialists, which could cost $10,000 or more per day. (Europeans have so far resisted this delusion, one reason they spend much less than we do on health care, with far better results.)

But we were wrong. Health care spending has since doubled, to around 16 percent of our gross domestic product, and in the next 25 years or so is projected to reach 31 percent of G.D.P. Despite having those figures in hand, Congress might still pass legislation calling for spending more, not less, on health care, even though we’ve been told for decades that what we spend has almost nothing to do with the quality of care we receive.

In fact, expensive care is often worse care, because it snowballs into what some are calling an “epidemic of overtreatment,” in which unnecessary procedures, tests and medications all spawn more tests, more meds (to treat the side effects of the first batch) and more follow-up scans and procedures (in stand-alone clinics owned by the same doctors prescribing the tests, scans and procedures).

With so much evidence of wasteful and even harmful treatment, shouldn’t we instantly cut some of the money spent on exorbitant intensive-care medicine for dying, elderly people and redirect it to pediatricians and obstetricians offering preventive care for children and mothers? Sadly, we are very far from this goal. A cynic would argue that this can’t happen because children can’t vote (even if their parents can), whereas members of AARP and the American Medical Association not only vote but can also hire lobbyists to keep the money flowing.

One thing’s for sure: Our health care system has failed. Generational spending wars loom on the horizon. Rationing of health care is imminent. But given the political inertia, we could soon find ourselves in a triage situation in which there is no time or money to create medical-review boards to ponder cost-containment issues or rationing schemes. We’ll be forced to implement quick-and-dirty rules based on something simple, sensible and easily verifiable. Like age. As in: No federal funds to be spent on intensive-care medicine for anyone over 85.

I am not, of course, talking about euthanasia. I’m just wondering why the nation continues incurring enormous debt to pay for bypass surgery and titanium-knee replacements for octogenarians and nonagenarians, when for just a small fraction of those costs we could provide children with preventive health care and nutrition. Eight million children have no health insurance, but their parents pay 3 percent of their salaries to Medicare to make sure that seniors get the very best money can buy in prescription drugs for everything from restless leg syndrome to erectile dysfunction, scooters and end-of-life intensive care.

Sir William Osler, widely revered as the father of modern medicine, said, “One of the first duties of the physician is to educate the masses not to take medicine.” Perhaps the second duty should be to administer an ounce of prevention instead of a pound of cure.

 

Richard Dooling is the author of “Critical Care,” a novel.

Health Care’s Generation Gap, NYT, 17.8.2009, http://www.nytimes.com/2009/08/17/opinion/17dooling.html