Tuesday, September 15, 2009

Closer to dying, far from dead

Photograph by Richard Avedon.
Jacob Israel Avedon, Sarasota, Florida, December 19, 1972.

(this portrait is part of a series that the photographer made to record his father’s last years)

It's often difficult to keep track of exactly how things happen out here on the Innertoobz, but I'll try to summarize one recent chain of events:

Yesterday, I stumbled across a blog called Boston Health News (BHN). I honestly don't know how I found it, but I'm glad that I did - the writing's excellent, and the news is timely - and I promptly added it to my blogroll category, 'Healthcare, Death, Life, etc.' I also posted a brief comment over there, and subsequently heard back from the blog's owner, health and science writer Tinker Ready.

Tinker also sent along the following email:
Hi Jerry, I like your blog and I like the name, but I’m not sure others will get it. So I’m going to link to you under “End of Life Care.” Let me know if that’s a problem.

I think it’s an important topic in this age of death panel-baiting. Thanks for checking in.

Links are the figurative coins of the blogging realm, and I think it's really important to find like-minded bloggers, read and comment on their stuff, and exchange links to promote each others' work when the fit seems right.

Tinker also told me about another of her blogs, Boston Boomer News (BBN).

I checked out a brief story posted at BBN on September 11, "Doctors need to ask different questions as you age," which led me to an assessment tool developed by the Health Committee at the Boston Partnership for Older Adults (BPOA). The tool provides guidelines to primary care providers for conducting a comprehensive functional assessment of older adults, and there are versions available in English, Chinese.

So, the story thus far: Innertoobz stumbling --> find BHN --> exchange comments, email, links with link-minded blogger --> learn about BBN --> read story at BBN about an assessment tool for PCPs to use with older adults --> go to BPOA.

The BBN story and the information at BPOA reminded me of a magazine article on the subject of aging I had read, written by one of my own favorite health writers, the surgeon and author Atul Gawande. That led me to a search for Atul's own web site, and subsequently to the reprint of his article, "The Way We Age Now."

Gawande's article includes an account of time he spent with Juergen Bludau, the chief geriatrician at the Brigham and Women's Hospital's Center for Older Adult Health in Boston, as Bludau examined a patient.
I tried to think what could be accomplished in this visit. She was in good condition for her age, but she faced everything from advancing arthritis and incontinence to what might be metastatic colon cancer. It seemed to me that, with just a forty-minute visit, Bludau needed to triage by zeroing in on either the most potentially life-threatening problem (the possible metastasis) or the problem that bothered her the most (the back pain). But this was evidently not what he thought. He asked almost nothing about either issue. Instead, he spent much of the exam looking at her feet.

“Is that really necessary?” she asked, when he instructed her to take off her shoes and socks.

“Yes,” he said. After she’d left, he told me, “You must always examine the feet.” He described a bow-tied gentleman who seemed dapper and fit, until his feet revealed the truth: he couldn’t bend down to reach them, and they turned out not to have been cleaned in weeks, suggesting neglect and real danger.

Gavrilles had difficulty taking her shoes off, and, after watching her struggle a bit, Bludau leaned in to help. When he got her socks off, he took her feet in his hands, one at a time. He inspected them inch by inch—the soles, the toes, the web spaces. Then he helped her get her socks and shoes back on and gave her and her daughter his assessment.

So, what's my point?

Well, I guess it's simply that in paying such careful attention to the needs of patients and families at end of life, we in this field can overlook the people who are far from dead, but who may be getting closer to dying.

Hmmmm, that sentence doesn't seem quite right. I can understand how somebody might misunderstand it or become alarmed, but I'm not sure how else to say what I'm trying to say.

How about this - any of us may reach the end of our lives suddenly, from a serious accident or other trauma; or we may come down with an illness that results in a series of sharp declines, perhaps interrupted by periods of reprieve or temporary improvement.

But those are just two models. There's at least one other trajectory, one where the slow but inevitable march of time takes away the things that are important to us, but takes them away in such small increments that we don't really notice until a large pile of accumulated pieces gets our attention, or the attention of others around us.

I don't have any answers or advice about what to do with this thought just yet, except maybe to note it as another link in the chain that started when I was stumbling around on the Innertoobz and found Tinker Ready and her blogs.

One other quick note - Juergen Bludau's a member of the Board of Directors at BPOA. Small world.


  1. I think it’s a great name. It doesn’t matter if anyone “gets it.” It fits your inviting writing style. And it’s quite memorable. Great topic for a blog. I look forward to reading more.

  2. As you note, if one lives into old age decline, at some point, becomes inevitable. It is hard to think about, and hard to think about what to do with this. That difficulty of thought is the reason I started my journals and, probably, the reason those journals contain so many millions of words, a lot of which signify little.
    The one productive thought I had about this situation in regard to my mother, though, was that when she asked me, sixteen years ago, to accompany her through the rest of her life, I thought, "yes", and followed that thought. It's the one and only thought that was truly responsible for the quality of her life from there on out. I dare say, while it's possible there could have been improvements, it was a pretty high quality. Certainly my mother was satisfied with it. So am I. In addition, once my mother wrapped up her life, neither of us had excuses for anything.
    So, there's a thought.