Thursday, June 12, 2014

Thoughts from Steve Miles

MinnPost's Susan Perry interviews the brilliant Dr. Steve Miles on whether (or not!) our society is ready for the coming wave of old people -- medically, infrastructurally, and more.

This guy is so amazing, there's too much to quote.

MinnPost: ...our medical system seems more set up for acute care during those last few days or months of life, not for helping people deal with the last 5 to 10 years.

Stephen Miles: Well, I think that’s true, but I’m going to make a provocative comment here. Medicare was really normed on a male life course, not a female life course. When Medicare benefits were set up, [they were based on the shorter] life trajectories of men. There would be a female caregiver available to care for the old guy, who passed at a relatively young old age. The women were more likely to develop chronic conditions and then move into institutional settings because they didn’t have a caregiver.

MP: But then men started living longer.

SM: When men started requiring medicines for chronic disease, that was when we added on Part D of Medicare [Medicare’s prescription drug benefit]. Men still don’t occupy nursing homes anything like the degree to which women do, and so that’s why nursing homes still sit on the Medicaid side of the budget, which is a state/federal share. 
Obviously one of the interesting things about that phenomenon, the female caregiver problem, is that it has a really far-reaching effect on the life trajectory of women workers. At the time when they should be eligible for promotions to leadership positions, they take up caregiving roles that essentially cut their work course participation as professionals substantially.
Plus this on how we, generally, think death happens in the U.S. vs. the reality:
MP: What are some of the misconceptions that we have about aging that get in the way of us — as individuals — from realistically thinking about how we’re going to map out our life for our last couple of decades?

SM: ... One of the interesting things is that if you ask people what percentage of deaths in the United States are preceded by decisions to withhold or withdraw sustaining treatment, they’ll typically give you numbers like 1 percent, 2 percent, or 5 percent, something like that. The real number is actually 95 percent, and the reason for that is that there are three trajectories of late-life care in the United States.

One goes like this: Somebody gets Alzheimer’s disease and dies. What happens is that they have a period of decline, possibly at home, and then they move to a nursing home. They may go back and forth to the hospital for a while, but then they’re kept in the nursing home and treated with palliative measures as they pass.

The second trajectory of end-of-life care in the United States is one that goes [like this]: Somebody gets something like pancreatic cancer. They’re treated aggressively for a while, and then they’re moved into a hospice program. They may go back to the hospital, perhaps for a few short pain-relief things, and then they pass with a supportive care plan.

The third course is some sort of catastrophic illness with septic shock. They are briefly evaluated, and then a limited treatment plan is set up.

But the problem is, if the population does not understand the planning for these decisions as normal life work rather than an exceptional one, they don’t undertake the task.
And then about infrastructure:
MP: What kind of late-in-life support services are needed, including here in Minnesota?

SM: Supportive services have to be [thought of] as a total ecology. The Twin Cities metro area is extremely poorly designed for this late-in-life lifestyle. The freeway system is not traversable, even for us younger guys. The housing is far spread out, which makes home-care services extremely difficult. Walking to essential services is quite a bit more difficult than in Europe. Bus service is scattered in routes that are far removed from any houses. And, particularly, once one moves to the first-ring and certainly the second-ring suburbs — and I won’t even comment on the third-ring suburbs — we basically have an urban and suburban architecture that is incompatible of supporting older people.
This is only part one of the interview... Perry follows up tomorrow with more on psychological issues of aging and declining health.


Here's part two, including this quote from the photo caption: "Miles on fighting depression among the elderly: 'Medications can get you 20 percent of the way there. Congregate dining will do much more, [as will] getting out of the house, moving, sunshine in the afternoon, socializing and exercise.'"

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