August 26, 2015

August 23, 2015

Palliative Care Comes of Age

Last week, the New England Journal of Medicine published a short review article entitled “Palliative Care for the Seriously Ill.” Eleven years ago, the NEJM also published a review of “Palliative Care,” at that time putting it in the section of the journal called “Clinical Practice.” What has changed over the decade? What has remained the same?

Comparing and contrasting the two short articles, both of which emanate from the Mount Sinai School of Medicine, reveals some interesting changes. Perhaps the first change worth noting is that the Mount Sinai School of Medicine is now the Icahn School of Medicine at Mount Sinai. That a venerable school of medicine should now be named after a business magnate known as a ruthless corporate raider instead of after the alleged birthplace of the Ten Commandments says worlds about developments in the field of medicine. Palliative care itself has been affected by the widespread corporatization of medicine, with 2/3 of all hospice providers for-profit in 2013, compared to 5% in 1990. But the article rightly concentrates on describing the field of palliative care rather than one specific program, hospice care. The authors carefully distinguish between the population who stand to benefit from palliative care--those with serious illness--and those who may benefit from hospice care--those who are in the last months of life.

What stood out reading the new and older articles side by side is that in 2004, Morrison and Meier were at pains to explain the rationale for the very existence of palliative care. They emphasized the under-treatment of symptoms such as pain, delirium, and nausea in very sick patients. They discussed the fixation of American medicine on cure, even when cure was not possible, and the false dichotomy between cure and comfort. In 2015, Morrison, writing this time with Kelley, a young colleague (also a marker of change as a new generation of physicians rises to prominence in palliative medicine), do not feel the same need to justify palliative care. To the extent that they do feel obligated to explain why palliative care should exist, they provide data, itself a welcome development over the past decade, offering a graph showing the prevalence of ten specific symptoms in advanced illness, broken down by disease category (cancer, congestive heart failure, chronic obstructive pulmonary disease, advanced kidney disease, dementia, and AIDS).

Another area discussed in some detail in the new article but scarcely mentioned in 2004 is the various delivery models for palliative care. Ten years ago, palliative care consisted principally of in-hospital consultation and of home-based hospice. Today, it is both of those but it is also increasingly provided in the outpatient arena and in the nursing home.

The discipline of palliative care is much the same today as it was a decade ago: it is based on the three-legged stool of communication (which includes establishing the goals of care and planning for the future), symptom management (which addresses symptoms from pain to constipation), and psychosocial and spiritual support (which is targeted to families along with patients). But it has grown into a mature field with a small but robust and burgeoning research base. It is an interdisciplinary form of care that offers an “added layer of support” to conventional care (words chosen from market research done by the Center for the Advancement of Palliative Care); it is for the “seriously ill,” (as the authors quietly insert into the title of their article), not just for the dying; and it is for people of “any age,” not just for older people (who seemed to be the primary target in the earlier article that emphasized the graying of the population).


The field has made remarkable strides. I have just one nagging concern. In its eagerness to view palliative care as a supplement to rather than a replacement for conventional care, the field has a tendency to ignore the important truth that when palliative care clinicians review the prognosis and the options with patients, the conclusion may well be that less is more. And in its excitement over the surprising finding in one important study that patients with palliative care may actually live longer than those receiving usual cancer care, the field glosses over the importance of making trade-offs between life-prolongation, comfort, and maximizing function. Sometimes, to be sure, there are no life-prolonging options: the aggressive chemotherapy that oncologists offer and patients seize upon simply won't work and may paradoxically shorten life. But sometimes--and I would argue more often--there is a potentially life-prolonging option. That course of treatment, however, is typically very risky. Its likelihood of succeeding may be extremely small and its probability of causing misery extremely high. What palliative care does in this scenario is to lay out the alternatives and figure out which makes most sense for a patient and family in light of their goals of care. What palliative care does not do, however, is deny the importance of making trade-offs. 

Perhaps when the New England Journal publishes a review article about palliative care in another ten years, the authors will not feel the need to view the field as an add-on, but rather as the more realistic and comprehensive approach to the management of advanced illness. The truth is that most of the diseases that kill people today--heart disease, many cancers, and dementia, for example--are chronic diseases. They cannot be cured. All treatment for these conditions is inherently palliative. Cardiologists, oncologists, and neurologists all practice palliative care all the time; they just don't do as good a job as they might. Here's to Palliative Care 3.0!

August 16, 2015

Til Death Do Us Part


Why did this image go viral? In case you haven’t seen it before, it depicts a couple who were admitted to separate rooms in a Georgia hospital. Thanks to the wisdom of the nursing staff—and some bending of the rules—they were reunited. I think the photo struck a chord because it captures the important reality that what matters most as we get older—and perhaps at any age—is relationships.
We devote an inordinate amount of effort when we are younger to being “successful,” which we tend to define in terms of fame and fortune. And then, when we retire, we focus on living longer, on diet and exercise, on health and on experiences. But what so clearly mattered most to the couple in this photo is each other. Yes, the oxygen flowing through the plastic tubing is important. Yes, the intravenous catheter (not visible in the photo but I’m reasonably sure it was there) was useful for delivering potentially life-prolonging medication. But what makes life meaningful above all is our connections to others.
Lisa Berkman, a prominent social epidemiologist, has found compelling evidence that social networks—our links to our community—even affect our physical health. They influence whether we get a heart attack or stroke in the first place and how we fare if we get one. They affect our propensity to develop cognitive impairment and how well we cope if dementia strikes. But perhaps George Vaillant said it best when summarizing his book, Triumphs of Experience: the Men of the Harvard GrantStudy. This ambitious, longitudinal project followed 268 men who graduated from Harvard in the 1940s with a series of in-depth interviews over the course of their lives. Of course, generalizing rom these privileged Americans, all male and all born in one era, to the rest of us is risky. But despite their talents and their opportunities, these men had their share of alcoholism, of poverty, of suffering, and of disease. The inescapable conclusion that Vaillant reached  was, as he put it himself: “It was a history of warm, intimate relationships—and the ability to foster them in maturity—that predicted flourishing in all aspects of these men’s lives.” And that's the message conveyed by the photo of the two nonagenarians in their hospital johnnies, holding hands.



August 09, 2015

Food for Thought

The global anti-aging industry is valued at over $195 billion and will grow to $275 billion by 2020. But the assessment of the effectiveness of its products made by three leading scientists in 2002 has not changed. And what they said is that “no currently marketed intervention—none—has yet been proved to slow, stop, or reverse human aging, and some can be downright dangerous.” They then go on to say that "the public is bombarded by hype and lies." Or, as one of the triumvirate put it in a recent NY Times article, "as soon as the scientists publish any glimmer of hope, the hucksters jump in and start selling."  
In light of this reality, my internal alarms started going off when I saw the headline in last week’s NY Times, “My Dinner with Longevity Expert Dan Buettner (No Kale Required).Granted, the article was in the “Fashion and Style” section of the Times, not the health section and not the science section. Now don't get me wrong: diet and exercise do matter: eating well and remaining active decrease the chance of developing disease and disability. Not only that, but modifying what you eat in the hope that it will promote longevity is far more benign than purchasing expensive supplements or herbal remedies that have no proven efficacy and are quite possibly harmful. But still—is Dan Buettner really a “guru of the golden years” who has spent “the last 10 year unlocking the mysteries of longevity?” He traveled to five of the places on the globe with the longest lived people: Icaria, Sardinia, Okinawa, the Nicoya Seaside of Costa Rica, and Loma Linda, California and wrote up his interviews. He was not funded by the NIH as the report would have us believe: he was funded by National Geographic to report on peoples who were being studied by teams of scientists funded by NIH. He did write a cover story for National Geographic in 2005 about the people he met on his travels and how they lived, particularly how they ate. And he converted his article into a book, The Blue Zone Solution, published by National Geographic Press this past spring.
            National Geographic ran a cover story about diet and longevity once before. The magazine reported in 1973 on Dr. Alexander Leaf’s travels to the Caucasus where he studied people who ostensibly were 120 years old. It would turn out that these human marvels were actually only in their nineties, at best. In fact, according to Dr. Tom Perls, head of the New England Centenarian Study, 98% of claims of age over 115 are false, as are 65% of claims to be 110. 
            I’m not sure why the NY Times ran this story. But I was sufficiently intrigued to look into what we do know about diet and longevity.

         For starters, it’s important to distinguish between people who live a long time and people who live a very long time. What is pretty clear is that the variability in life span for people in the first category can be explained by a mixture of environmental and genetic factors. We can’t control who our parents were, but we can control, to some extent, our environment. So what we eat is one of the things that does matter, at least as far as increasing our chances of making it into our eighties is concerned. Exceptional longevity—centenarians and “super-centenarians” (people over age 110) are a different story. For this group, it’s all about genetics. 
            But can we say much more than what was concluded from the Whitehall study, a longitudinal study of aging in Canada that found the 4 behaviors that increased the chances of being in good health after age 60 are regular physical activity, eating fruits and vegetables daily, drinking alcohol in moderation, and not smoking? What do we learn by looking at  the dietary habits of people in Buettner’s “blue zones” of above average longevity?  
          For several decades, geriatrician Bradley Willcox and his twin brother, anthropologist Craig Willcox, have been leaders of the Okinawan Centenarian Study. They have identified a variety of factors which, together, seem to account for the long lives of Okinawans. It’s not just about diet. It’s also about living in a culture that values group activities and fosters a strong sense of community. It’s about living in a slower paced, low pressure world where people get around by bicycle. But yes, it’s also about diet. And while each of the longevity hot spots of the world has its own culinary specialties, they all have much in common. They all feature a high intake of unrefined carbohydrates and a moderate intake of protein, mainly from fish and legumes. Their foods have a low glycemic load, include a goodly number of anti-oxidants, and are low in saturated fats.
         How much of a role diet plays in the 30-50% of longevity that is due to environmental factors is unclear. Also unclear is whether diet interacts with social factors to make a difference. It’s conceivable that what you eat matters, but it matters a good deal more if you also live in an all-embracing community. At least as interesting as the Sardinians and the Costa Ricans are the Seventh Day Adventists of Loma Linda (whom, to be fair, Buettner visited as well). The people of Loma Linda are physically active and tend to be vegetarians. They are also very involved in their community and deeply committed to their religious faith. So maybe, just maybe, it’s not only what we eat that determines how long we live. Just some food for thought.

August 03, 2015

Medicare: the Great Facilitator

On July 30, 1965, President Lyndon Johnson signed Medicare (and Medicaid) into law. In the last fifty years, it has evolved further—adding coverage for those with disabilities, regardless of age, ditto for those with advanced renal disease; adding a hospice benefit, a prescription drug benefit; and creating a private, managed care alternative (most recently known as Medicare Advantage plans). Along the way, it has stimulated changes in the way health care is delivered to its now 40 million members by introducing prospective payment for hospital care (resulting in shorter hospital stays and the burgeoning of the post-acute industry), by promoting the integration of care across multiple sites (office, hospital, nursing home) through the creation of Accountable Care Organizations, and by beginning to pay for quality rather than volume (incentivizing physicians, for example, to prevent readmissions after patients have been discharged from the hospital). So what do we know about the impact of Medicare on patients’ health and well-being? The most recent issue of the Journal of the American Medical Association is devoted almost entirely to the effects of Medicare. The results? Older patients (and others covered by Medicare) are doing better than ever.

Mortality for patients enrolled in Medicare fell from 5.3% in 1998 to 4.4% in 2013, a sizable drop. Now just because Medicare patients did better doesn’t mean that Medicare caused the improvement. The great improvement in mortality at the beginning of the twentieth century was attributable primarily to better public health—things like clean water and improved sanitation—rather than to medical interventions, as Rene Dubos explained in his seminal  1959 book, Mirage of Health. More recently, Michael Marmot has persuasively argued that longevity is affected by the position in the social hierarchy, by which he means relative position in the pecking order, not just income or education. So while medical care does matter—there has been a marked decline in mortality from heart disease, due at least in part to new medications and coronary care units, not just to better nutrition and exercise—it’s rarely the whole story. And there’s good reason to believe that while Medicare didn’t cause the recent fall in the death rate directly, it did facilitate the decline by paying for hospital care, medications, and outpatient treatments.

Other trends are similarly impressive. Hospitalization, at least among patients enrolled in fee-for-service Medicare (we unfortunately do not collect data on patients enrolled in Medicare Advantage programs except whether they die), also declined: from 35 hospitalizations/10,000 person-years to 27 from 1999 to 2013. Hospital length of stay fell also, from a median of 5 days down to 4. And fewer people end up in the hospital during their last month of life. All this while Medicare expenditures per person fell from $3250 to $2800.

As with mortality, these other trends are associated with enrollment in Medicare but cannot be assumed to be caused by the Medicare program. But what is clear is that, as I argued in my paper, How Medicare Shapes the Way We Die, Medicare is the great facilitator. It affects what we die of, where we die, when we die, and how we die. In particular, it helps determine the procedures we have, the drugs we take, and the diseases we suffer from. It achieves this by providing a stimulus to inventors to innovate and device manufacturers to produce machines and physicians to promote them, just because the inventors, manufacturers, and physicians were guaranteed to be handsomely reimbursed for their work.  The new data suggest that Medicare does the same for the way we live when we are old. Here’s to the next fifty years!

July 28, 2015

How Much Good Could the WHCOA Do if the WHCOA Could Do Good?

A few weeks ago, I blogged about the upcoming White House Conference on Aging. This once-a-decade event took place last week. What, if anything, did it accomplish?

It was a modest affair, attended by a mere 200 invited delegates (though observed on line by 600 “watch parties”) that was more of a highly scripted performance than a platform for hashing out policy recommendations. This was no surprise, as Congress never allocated funds to support the event, so that it took place at all is something of a miracle. For all its limitations, it did accomplish something.  It was of symbolic significance, a way for the White House to affirm that the health and well-being of the older population are a concern for the entire society. It was also a forum for presenting recommendations for what people outside the federal government can do to address important public policy issues—given that Congress refuses to do so.

The Conference was of symbolic significance: it was hosted by the White House and the President actually made an appearance, addressing the attendees. And it turned to groups other than Congress to implement policy. In particular, it turned to state government, to the nursing home industry, and to the corporate world. State governments were exhorted to adopt 401K type savings plans for older people—a corresponding initiative, incidentally, failed in Congress. The nursing home industry will be charged with implementing a lengthy set of new rules proposed by the Centers for Medicare and Medicaid Services designed to improve quality of care in nursing homes. This means the nursing homes will have to pay for the enhanced training for nurses and nurses aides that the regulations would mandate as well as infection control committees to monitor antibiotic use and a host of other mandates. And corporations were given shining examples of creative technological approaches to the problems of aging: the ride-sharing service, Uber, detailed a new program that will offer older people discounted or free rides and training in using its smart phone app; Philips announced the creation of its “AgingWell Hub,” a collaboration with caregivers, older adults, academics, and companies  to identify new technologies and services that promote successful aging.

All in all, the Conference gave a boost to ongoing efforts in its four main topic areas: healthy aging, long term services and supports, elder justice, and retirement security. It was not an opportunity for brainstorming or for developing bold, radical new ideas. But it was a pragmatic approach to a pressing problem, undertaken with a paltry budget. And maybe, just maybe, Congress will be moved to do more in the coming years. After all, the average age of the current senators is 62, which means that before their term is over, the majority will be eligible for Medicare.

A longer version of this post appeared on the bmj blog