Category Archives: Operating Committees

Moving Modern Geriatrics to Take Advantage of Nurse, Family and Patient Intuitions

As our strategic plan moves forward in the health area, we are given a useful reminder in the New York Times of the value of instinct in alerting people to potential medical crises.  The Times article focus on the instincts of nurses, and is fascinating.  I have done a blog that asks if we can also take value from the intuitions of the family and the patient themselves

I suspect that we could “train” patients and families to be much more mindful about patient monitoring, including how to trust their instincts and how to communicate their feelings to the medical personal.  This, of course, should be accompanied by training of medical staff on how to take the most advantage of, and how to solicit such communications.  It is not hard to construct model ways of doing so.

I suspect that when things work, that is very much happening in our long term care facility already.  Nurses and care staff know the patients, and communicate with them regularly.  It makes such sense to empower them to raise their concerns, to train and encourage family and resident to do so too, and finally to ensure that all medical personnel not only listen to, but affirmatively seek such help as part of an inclusive team.

I am sure that this will fit in well with our general themes of community cultural change and inter-generational initiatives, as well as the specifics of modern geriatric medicine.

 

 

Denny Klass’ Thoughts on Palliative Sedation

Editor Note:  Collington is lucky to have as a resident and resource Denny Kass, a renowned expert on issues relating to death and mourning.  A recent Washington Post article on how doctors can and do take steps that have the effect of easing the path to peaceful painlessness within the constraints of current law caused us to ask Denny to reflect on the rapidly changing landscape for us at Collington.  The key  quote from the post is : “Under palliative sedation, a doctor gives a terminally ill patient enough sedatives to induce unconsciousness. The goal is to reduce or eliminate suffering, but in many cases the patient dies without regaining consciousness.”  The opinions expressed are personal to Denny.

Will someone help us die when we are ready? The question has been, in different forms, part of the ongoing conversation at Collington for a long time. Last year the majority of Collington residents signed a petition to the Maryland legislature supporting an Oregon-style assisted dying law. A bus load of residents lobbied for the law in Annapolis. In February this year four residents attended a two-day conference on assisted dying at the National Science Foundation.

In this brief posting I will think about a few issues and possibilities in assisted dying in a way that I hope can help our community focus the discussion.

Physician assisted dying (PAD) modeled on Oregon’s law is now legal in several states. I believe the recent appointments to the Supreme Court will make it harder for PAD advocates, and because its opponents link PAD with abortion, the Court may restrict PAD as part of reversing Roe v. Wade.

Not having Oregon-style PAD actually has little effect at Collington. Those laws do not really fit our situation. The laws permit physicians to give lethal drugs, after many safeguards, to people who have a disease, usually cancer, that will kill them within six months. The same prognosis qualifies a person for Medicare to cover hospice. Howeer, that’s not the way most of us will die.

As we look around us, we can easily see that advanced aging is a series of debilitating physical and cognitive changes that slowly eventuate in death. Many of us have included Do-Not-Resuscitate (DNR) orders on our MOLST forms in the hope that if death comes quickly, emergency responders will not reverse it. But that will not happen for most of us.

An article in the Washington Post last week explored palliative sedation, a long-standing way physicians in both acute care and hospice have been legally assisting dying for a long time. The practice rests on a distinction between active euthanasia — giving medications to cause death, and passive euthanasia — giving medications (usually morphine) to relieve pain that may as a side effect hasten death. Thus passive euthanasia is treated the same as withholding or stopping active treatment.  The article notes that the opponents of PAD accept this distinction. Palliative sedation will probably escape legal changes in assisted dying that I think are coming in the next few Supreme Court sessions.

The Swiss have a different kind of PAD law in which all competent individuals retain their autonomy to determine their own manner of death. Individuals can decide when death is preferable to living. The film You Before Me was about a young quadriplegic traveling to Switzerland to die. In early May, we read news articles about  104-year-old Australian scientist David Goodall who took what he called the Swiss option. I think, however, the ultra-conservative Supreme Court majority would oppose a Swiss type law in the United States.

In the present legal climate, we can ask whether palliative sedation could be extended to the trajectory of dying most of us are on. Old age is a terminal condition. Even though it is composed of many diseases and syndromes old age always ends in death. The question remains: Will someone help us die when we are ready? Each of us could decide for themselves when our failing capacities makes death a better option than living, and after we have made that decision, could we ask to be put into a drug-induced coma that will hasten death.

For many in our community individual autonomy is the prime value. The opponents of PAD do not hold individual autonomy as a prime value. They think whether we live or die is God’s decision. Our Collington community is open to many religious beliefs. If some of our members wish to wait for God to decide their time has come, we should provide whatever support they need to be comfortable while they wait. Could Collington provide as much support for those who decide death is better than living as we provide to those who choose to wait for God?

The Potential for Clinical Trials at Collington

As we move forward with our repositioning of health care at Collington,  of necessity the potential of Collington as a research location has taken a big of a back burner – but only for now.

This New York Times article is a timely reminder of how us seniors are often forgotten when it comes to clinical trials:

Salt matters to geriatricians. It’s associated with conditions many older people contend with, particularly high blood pressure, but also swelling and heart failure.

Though doctors frequently urge older patients to reduce salt in their diets, it’s not clear how much reduction is necessary to improve health, or even how much salt most people actually consume.

“There’s a lot of controversy, but that’s why we need the data,” said Dr. Covinsky. So he read on, until he reached the paragraph explaining that the study used “randomly selected, nonpregnant participants aged 20 to 69 years.”

He did a double-take. Once again, the population probably most affected — older adults — had been left out of an important study.

“How is this possible? Unacceptable!” Dr. Covinsky protested on Twitter. “I can think of no good rationale for this exclusion. This has got to stop.”

Indeed, I have been told by researchers that it is hard to recruit seniors for trials.  This may be for a variety of reasons, lack of trust, fear of the unknown, inconvenience, failure to understand modern protocols and informed consent.  As the Times adds:

Starting next January, [NIH] grant applicants will have to explain how they intend to include people of all ages, providing acceptable justifications for any group they leave out. The agency will monitor investigators to make sure they comply.

Moreover, there are often problems with exclusions of research candidates who have multiple medical conditions (like almost all seniors.)

This has all led to the idea that Collington may indeed be a perfect research partner.  We have many scientists here, and many with experience with statistics, data, and research protocols.  We are an easy to reach population, and we are also racially diverse — another important consideration.  Moreover, we might be able to help enroll and provide services associated with the research to those in the community.  (In particular, fear of not being helped with other conditions is a major deterrent to certain categories of patients.

So, as we move forward, lets keep this is mind.

Salt, anyone?

p.s. Dorothy Yuan adds the following thoughtful comment.

You have absolutely right that we have an ideal population for clinical trials.  I can already think of many parameters.  First, the age bracket is quite limited.  Second, living conditions are similar.  Third,  access to minimal  medical care is generally available.  Forth, although the daily menu provides a lot of choices it is still rather limited in scope. Fifth, and most important, easy access for researchers to do follow-ups.
Whereas these conditions are not suitable for all areas of study.  For example, salt intake will be rather difficult since we don’t prepare our own meals.  However, we would be ideal for many other studies.  
All we need is a way to advertise our availability. 

 

News and Perspectives on Strategic Planning and Implementation Steps

Editors Note:  Periodically we post perspectives pieces in which we offer some broader thoughts on where our community is going.  We do this not only for each other, but to show our friends what is happening here.

As many know, our Strategic Planning document has been published, and concrete steps have been announced to move its items forward (see page 15 of our Courier dated Feb 26 to March 4).  This is a very important document for all of our lives, and not just because of the concrete steps, such as completely repositioning our health care, that are being and will be undertaken under its banner.

Every few weeks, the Committee, which is a Board Committee with heavy resident and staff participation, will be releasing an update on activities and plans in the Courier.  Residents will also be hearing about that in various fora, including the RA Council and the Community Meeting.

Indeed, such an update is in the most recent Courier.  It includes the very important news with respect to the critical health care partnership, that:

After a significant amount of due diligence, we have narrowed potential partners down to 3 providers. We are continuing due diligence and believe a final recommendation will be made to the Board in June for their endorsement.

Similarly with respect to the physical redesign of the Creighton Center (which is of course deeply integrated with our conceptual redesign:

A Request for Proposals (RFP) has been developed and has gone out to several national and local architectural firms. An ad hoc committee of the Strategic Planning Committee will oversee the RFP process and final recommendations on an architecture firm. We expect this process to be completed by the end of June as well. 

The is no need to note what a wonderful acceleration this represents.

The Report notes that the “Collington Culture and Stakeholder Engagement” implementation rollout will begin in September, and the other two will start in 2019. This delay will enable us to take full advantage of what we are learning about how best to work together in the initial groups and apply that will the next ones.

Speaking for my self, I feel very confident that these processes will be rich in resident input, and that the transformative quality will be clear from how things work out  Just look at the Landing Bistro and the new Physical Therapy staff and spaces.  These both reflect the values and principles processes established in the Srategic Planning process.  I hope that these will similarly increasingly influence everything here at Collington.

 

 

 

 

Meet Dr. George Hennawi – As described by his colleagues – A great guy, a straight shooter, his patients love him

On April 19th, a much anticipated program took place as over 100 Collingtonians packed our auditorium and an unknown number watched from home on channel 972. Dr. Peter Fielding, Chair of the Health Services Committee, introduced us to Medstar Gerontologist, Dr. Hennawi.

Dr. Hennawi presented his vision for medical care here at Collington based on a model already in place in Baltimore. As he demonstrated his enthusiasm, his presentation included statistics documenting this model of care’s success. Watch for yourself, understand the future of gerontology and how we may be part of that trailblazing experience!