Thursday, May 05, 2016

How We 'Know' Things Determines How We Handle Them. Old Age, Mental Health, Death

A book -

Atul Gawande's Being Mortal   
a movie

Healing Voices -  
and this
 LA Times article about medical error being the third highest cause of death behind heart attacks and cancer 
all have come together this week.  Their topics overlap somewhat, but more important, they all are great examples of the theme of this blog - how do we know what we know?

Being Mortal  is a doctor's reflections on how the medical profession thinks about and thus handles older patients.  Doctors, he tells us, are trained to cure people, but old folks aren't going to get better.  Doctors are technicians he tells us, so they fix the various discrete parts rather than the whole person.  By extension, as old folks begin to fall, get frail and forgetful, safety, not happiness, becomes the main concern of doctors and nursing homes.  What older folks need though, is to have some feeling of control of their lives.  Being ripped out of their environments and moved into sterile nursing homes takes away that control and all the cues that remind them of who they are.    

He writes extensively about the kinds of care available for people in the latter stages of life.  And he gives examples of places that are changing, compromising safety a bit to make being human the top priority - such as the doctor who stuck living (instead of the plastic) plants in every room, parakeets in every room, and dogs and cats throughout the facility and witnessed people coming back to life.  He had to overcome staff resistance as well as board and regulatory concerns, but it had huge positive effects on the people in their institution.   Here's an excerpt:
"The problem with medicine and the institutions it has spawned for the care of the sick and the old is not that they have had an incorrect view of what makes life significant  The problem is that they have had almost no view at all.  Medicine's focus is narrow.  Medical professionals concentrate on repair of health, not sustenance of the soul.  Yet --- and this is the painful paradox ---  we have decided that they should be the ones who largely define how we live in our waning days.  For more than half a century now, we have treated the trials of sickness, aging, and mortality as medical concerns.  It's been an experiment in social engineering, putting our fates in the hands of people valued more for their technical prowess than for their understanding of human needs.  
That experiment has failed. "

Having just watched my mother go through this, I find all this very compelling.  I first learned about the book about a year ago when my mother's neighbor recommended it and said, "Steve, keeping your mom at home was the right decision."  It was reassuring at the time, but I didn't start to read the book until it became this month's choice in my book club.

Keeping her at home where she could eat what she wanted to eat, when she wanted to eat it, at her own dining table, on her own dishes, seemed important.  Letting her sit in her wheel chair on her front porch among the plants and flowers she had tended for 60 years, seemed important.  We were incredibly lucky to find a caregiver she clicked with and to be able to pay for the caregiver and regular flights to Los Angeles.  That's a luxury.

And now I'm reading it with myself in mind.  How will my family and I deal with me when I get to that point of not being able to care for myself?  Ideally, I'll just sleep in one morning never to awaken just as I'm getting to that point, but that's wishful thinking.

Healing Voices  was a film we saw this week at the Bear Tooth about how the medical field thinks about mental health, the influence of the drug companies on doctors, and the need for patients to be treated as whole people and not to be labeled in ways that dismiss them as unable to be a part of their own recovery.  Here's the trailer:

Finally, the identification of medical error as the third highest cause of death after heart attacks and cancer, is another example.  Error wasn't considered a disease, so it wasn't listed as the cause of death, and so it wasn't identified as something to be addressed with the same urgency as diseases.  Again - how one sees the world, classifies what one sees, affects profoundly what one notices, and thus the options available for making effective changes.  An excerpt:
"The CDC currently has no good way of tracking deaths that result from medical mistakes, the authors wrote. The agency’s statistics are pulled from the International Classification of Diseases codes that appear on death certificates. These codes were instituted in 1949 and do not include any that indicate a death was the result of a mistake in the hospital."

All three examples involve a mental picture of the world that tells the person (or group of people) what the important values are and what parts of the world to pay attention to.  In each of these cases, those models left out very important aspects of the situations they were trying to improve.  Thus their solutions were inadequate and even harmful.

Each of us filter the world around us with various models that focus on some things and block out other.  I find no other explanation to why people watching the same presidential election, come to wildly different conclusions about whom to vote for.  It's important to constantly be testing one's own models.  It's also important to avoid simply dismiss the other guy as 'crazy,'  but to try to understand the model he's using to rationally get to his very different conclusions.  That's when communication and change can happen.


  1. Dear Steve and everyone,

    Agreed, change happens through what we know. Just as it’s ageing in Britain, it's aging in America.

    I’ve found why and what I learn; where and how I take in news; when and why I discuss these matters with friends, all work toward what I believe I know. Of course, this all comes well after our parents’ inculcation, religious and state indoctrination, making childhood friends (and not) and finally, living out our terrible teens!

    I would think these things and others affect the way all of us see our world. But there is another influence I've found important: where one chooses to live. Several examples come to mind and certainly one that's in the news in Britain recently, is whether one is anti-Semitic for opposing the presently-constituted State of Israel. While I lived in the USA, supporting the State of Israel ‘proved’ one wasn’t anti-Semitic. It was true for the left and became true for the religious right.

    When I arrived in Europe (where anti-Semitism was/is likened to racism in America), I pulled up a chair and listened to Europeans. I read, chatted over coffee and give it all a think. While doing this, I stumbled on history of Zionism and Jewish settlement in Palestine. I chatted with Israelis and Palestinians and people whose work took them to Israel, especially Quakers. It all led to shifting my views on the question of the Palestinian state.

    I get that we live in a world convulsed by globalization, itself shaped by liberal thought aspiring free movement in trade, people and ideas. Yet Israel, as a country once more, wanted nothing more than what all nations dare to possess: self-determination. Israel’s problem is that a one-state solution makes Palestinians stateless. In Britain, some are accusing those who oppose Israel’s one-state polity for being anti-Semitic.

    I guess it’s not convincing me to duck any more. What I once held is not now what I believe. Maybe it came with being dual national: I know it’s possible to have two nationalities exist in me. I leave it to you to decide if it’s possible for a nation.

    1. Since you brought it up, let me offer my two cents.
      There's anti-semitism which is like any prejudice and resultant discrimination that comes from judging individuals based on believed characteristics of the group they appear to belong to.

      There is opposition to Israeli policy on Palestine, which may or may not be conflated with anti-semitism, or be a cover for anti-semitism, or may simply be pro-Palestinian rights.

      When people opposing Israeli policy on Palestine attack (verbally or physically) Jews who are not Israeli, one begins to suspect this is the conflated form, or the one is a cover for the other.

      One also has to wonder how people in the US and Europe come to make anti-Israelism a major focus of protest when they do not address much more brutal and dictatorial treatment of people in neighboring countries. How do Israel’s wrongs get to the top of the evil list? Are they being held to a higher standard? If so, why?

      I personally find the Israeli government’s behavior in the West Bank and Gaza both appalling and ultimately self-defeating. But I also believe that any country a) surrounded at close range by people who deny its right to exist and attack that country with military weapons whenever they can, and b) has the power to protect itself, would have done far more damage than Israel has done to Palestinians. Russians invaded Ukraine because they felt threatened by NATO. The US was ready to start WWIII over missiles in Cuba and then went to Viet Nam to protect itself from Communism. England occupied Ireland. And the Republican presidential candidate who wants to build a wall along the Mexican border won the most votes.

      It’s important to remember Israeli geography. Israel is 9.3 miles wide at its narrowest point. You could walk that in three or four hours. And 85 miles at its widest.

      Ramallah is 12 miles from Jerusalem. Watford and Uxbridge are 15 miles from London. Imagine the British reaction to rockets launched into London from those towns. Would there be checkpoints to get into London?

      Gaza City is 47 miles from Jerusalem. Cardiff is 132 miles from London. Again, consider Cameron’s reaction to rockets into London from Welsh nationalists. And if they were being supplied by the Irish and Scottish? Or the French? In that context, I dare say that Israeli response is rather timid. The Arabic nations surrounding Israel could could have easily absorbed all the Palestinians in refugee camps if they really had wanted to help raise the living conditions of Palestinians. But keeping the Palestinians suffering allowed them to focus political anger in their own countries away from themselves and onto Israel.

      I can argue both sides of this issue and I do depending on who I’m talking to. Israel should have built good housing and good schools for Palestinians long ago. They should have treated them with respect. I think it would have gone a long way. But Israelis will tell you the Middle East is a tribal neighborhood where people still fight centuries old battles and nothing they would have done would have changed things. I don’t know the solution, but I know that everything about it is far more complex than most people want to know about. “Good guys” and “bad guys” is even used by so-called news reports these days. I just want to say, in that jargon, there are good guys and bad guys on both sides. And the good guys are not all good and the bad guys aren’t all bad. And individual Israelis have close friendships with individual Palestinians. And there are those who have a vested interest in the tension and kill off the peace makers - on both sides.

      I admire those who are working hard to create a sincere and lasting peace in the area. It’s a long and wearisome task.

    2. Happened again. Worked up a good, thoughtful reply to have it evaporate when I hit a radio button I didn't look at carefully before clicking it: Sign out.

      NO! Not sign out! I meant publish!

      Oh well. Gone.

      In short, let's just say I was recounting how the State of Israel is burning bridges where I live now.

      Yeah, I know. Quite a comment from someone who knows a thing or two about setting bridges alight...

      My point, exactly.

  2. Steve, it's 18:45 in London and the mayoralty has been called by news editors for Sadiq Khan, the Labour candidate, a human rights lawyer and British Muslim. It's a big step forward in face of fear.

    Officials will announce shortly. I'm proud of being a Londoner tonight!

    1. Congratulations. I know nothing about either candidate, but there is symbolism here that is important. Just as electing a black US president had important symbolic value.

  3. Fearing to be flippant after Jacob's good news, I give you my husband's answer my asking him, "What is the third largest cause of death in America?" Without a pause, he said, "Ricochet."

    An important post: I had to watch my parents being held ransom by the American system of "farming" (obviously dying) people for profit.

    The Boomers are coming up to decisions about their own last days/years. I told my family, after seeing what happened to my parents: I will off myself before I linger like that. They understood. But as of a few months ago, doctor-assisted suicide is now legal in Canada, another progressive thing to be thankful for, living here.

    1. Being Mortal raises many key issues in this evolution on how we think about the end of life and is being read by doctors and used in medical schools. It's important to stop now and then and think about what is truly important in one's life and how one wants to spend one's precious time - whether that's ten years or two weeks.
      And tell your husband to stop listening to the news so he doesn't have such a distorted view of violence in the US. :)

    2. He hasn't listened to the news since Obama was first elected, but seems to understand the big picture despite that and has a wicked sense of humor. He's British.


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