5/2/2011

1

Slow Medicine: Slow Medicine: ReRe--balancing Eldercarebalancing Eldercare

Dr. Dennis McCulloughDr. Dennis McCulloughDartmouth Medical SchoolDartmouth Medical SchoolHanover, New HampshireHanover, New Hampshire

Eldercare, a World of DilemmasEldercare, a World of Dilemmas

Evaluating and managing cognition Evaluating and managing cognition impairmentimpairment

Depression....or not...Depression....or not...

StrokesStrokes----ancient small bigancient small big

22

StrokesStrokes ancient, small, big...ancient, small, big...

Driving...Driving...

POLST, MOLST, COLST...POLST, MOLST, COLST...

Polypharmacy / overmedication...Polypharmacy / overmedication...

Money / time Money / time

44

Why Slow Medicine?Why Slow Medicine?

ComplexityComplexityp yp y

Fragmentation of CareFragmentation of Care

5/2/2011

2

FRAGMENTATION OF CAREFRAGMENTATION OF CARE

More and more “More and more “--ists”ists” SpecialSpecial--istsists

HospitalHospital--istsists

TransitionTransition--istsists

SNFSNF--istsists

LTCLTC--istsists

OfficeOffice--istsists

HomeHome--istsists

Palliative carePalliative care--istsists

HospiceHospice--istsists

IncidentalomaIncidentaloma--istsists

The Medical Model The Medical Model / Social Model / Social Model

55

InterfaceInterface

77

BackgroundBackground

PACEPACE

66

EvercareEvercareMedicaid WaiverMedicaid Waiver

Kendal retirement communityKendal retirement community

88

5/2/2011

3

SLOW MEDICINE’S SLOW MEDICINE’S FIVE FIVE

FOUNDATIONFOUNDATION

77

FOUNDATION FOUNDATION STONESSTONES

99

I.I.

AGING EDUCATIONAGING EDUCATION----How How do we orient ourselves, our do we orient ourselves, our

88

,,communities, our patients and communities, our patients and

families (in an agingfamilies (in an aging--averse averse society)?society)?

1010

II.II.

DEPENDENCY (and interDEPENDENCY (and inter--

99

dependency)dependency)----challenging challenging individualism: the New Ethics individualism: the New Ethics

of Eldercareof Eldercare

1111

5/2/2011

4

III.III.

COMMUNICATIONCOMMUNICATION----Shifting Shifting

1010

from Information Giving to from Information Giving to Active Listening Active Listening

1212

IV.IV.

COVENANTAL CARE AND COVENANTAL CARE AND

1111

ADVOCACY (in the face of ADVOCACY (in the face of failing Primary Care)failing Primary Care)

1313

V.V.

THE PRIMACY OF THE PRIMACY OF

1212

KINDNESS (in our hurried KINDNESS (in our hurried world).world).

1414

5/2/2011

5

The Journey of Late LifeThe Journey of Late Life

StabilityStability

CompromiseCompromise

DeclineDecline

Prelude to DyingPrelude to Dyingpp

CrisisCrisis

RecoveryRecovery

y gy g

DeathDeath

Grieving / LegacyGrieving / Legacy

StabilityStability

CompromiseCompromise

5/2/2011

6

CrisisCrisis

RecoveryRecovery

DeclineDecline

5/2/2011

7

Prelude to DyingPrelude to Dying

DeathDeath

Grieving / LegacyGrieving / Legacy

5/2/2011

8

WHAT ISWHAT ISSLOW MEDICINE?SLOW MEDICINE?SLOW MEDICINE?SLOW MEDICINE?

FAST FOOD / FAST FOOD / SLOW FOODSLOW FOODSLOW FOODSLOW FOOD

SLOW CITIESSLOW CITIESSLOW TRAVELSLOW TRAVELSLOW MONEYSLOW MONEYSLOW MONEYSLOW MONEY

SLOW PARENTINGSLOW PARENTING

5/2/2011

9

LOCAL INGREDIENTS, LOCAL INGREDIENTS, FAMILY RECIPESFAMILY RECIPESFAMILY RECIPESFAMILY RECIPES

CULTURAL CONTEXT AND CULTURAL CONTEXT AND PATIENT AND FAMILY PATIENT AND FAMILY

VALUESVALUES

SIMMERING ON THE BACK SIMMERING ON THE BACK BURNERBURNERBURNERBURNER

5/2/2011

10

PACING ALL ELDERCARE PACING ALL ELDERCARE DECISIONSDECISIONSDECISIONS DECISIONS

BIG TABLE, LONG MEALSBIG TABLE, LONG MEALS

ENLARGING SUPPORT, ENLARGING SUPPORT, S S A G A OCACS S A G A OCACSUSTAINING ADVOCACYSUSTAINING ADVOCACY

5/2/2011

11

Slow MedSlow Med 176.6176.6 62.762.7

Comp 1Comp 1 217.7217.7 187.l187.l

Comp 2Comp 2 209.9209.9 187.9187.9

Hospital Admissions / 1,000 enrollees Hospital Admissions / 1,000 enrollees /yr/yr

Comp 3Comp 3 260.7260.7 142.7142.7

Comp 4Comp 4 272.9272.9 182.2182.2

Comp 5Comp 5 292.8292.8 289.7289.7

DARTMOUTH ATLASDARTMOUTH ATLAS——UNPUBLISHED DATAUNPUBLISHED DATA

Other outcomes studiedOther outcomes studied

Surgical admissionsSurgical admissions--no changeno change

Medical admissionsMedical admissions--decreaseddecreased

ER visitsER visits--decreaseddecreased

EOLEOL——hospital days, ICU days, physicians hospital days, ICU days, physicians seen, specialists seen, hospital revenuesseen, specialists seen, hospital revenues——in 3 in 3 years preceeding deathyears preceeding death--decreased decreased

Elder and family satisfactionElder and family satisfaction--increasedincreased

In our quest for quality in the In our quest for quality in the late years of life, Slow late years of life, Slow

Medicine brings together the Medicine brings together the best “medical caring” with ourbest “medical caring” with ourbest medical caring with our best medical caring with our ageage--old traditions of support old traditions of support

and caring for elders and their and caring for elders and their families.families.

5/2/2011

12

My Mother, Your Mother: My Mother, Your Mother: Embracing “Slow Medicine” the Embracing “Slow Medicine” the

Compassionate Approach to Caring Compassionate Approach to Caring for Your Aging Loved Onesfor Your Aging Loved Ones

Dennis McCullough, M.D.Dennis McCullough, M.D. www.MyMotherYourMother.comwww.MyMotherYourMother.com

SLOW MEDICINE SUGGESTED READING—Spring 2011Drdennismccullough@gmail.comwww.MyMotherYourMother.com

A History of Old Age, Edited by Pat Thane, London: Thames and Hudson, 2005.

Athill, Diane, Somewhere Towards the End, New York: W.W. Norton, 2008

Bynum, J., D. McCullough et al, “A Medical Home where the Patient Lives: Collaboration between Primary Care Providers and Continuing Care Retirement Communities”, Health Affairs, May 2011.

Gawande, Atul, “Letting Go”, The New Yorker, August 2, 2010.

Gross, Jane, A Bittersweet Season: Caring for Our Aging Parents--and Ourselves, New York: Knopf, 2011.

Kleinman, Arthur, “On Caregiving”, Harvard Magazine, July-August 2010.

McCullough, Dennis, My Mother, Your Mother: Embracing “Slow Medicine”, the Compassionate Approach to Caring for Your Aging Loved Ones, New York: HarperCollins, 2008.

Morrison, Mary C., Let Evening Come: Reflections on Aging, New York: Doubleday, 1998.

Olds, Jacqueline M.D. and Richard Schwartz, M.D., The Lonely American: Drifting Apart in the Twenty-First Century, Boston: Beacon Press, 2009.

Paley, Grace, Fidelity (poems), New York: Farrar, Straus and Giroux, 2008.

Starr, Paul, The Social Transformation of American Medicine, New York: Basic Books, 1982.

The Oxford Book of Aging: Reflections on the Journey of Life, Edited by Thomas R. Cole and Mary G. Winkler, Oxford: Oxford University Press, 1994.

Thaler, Richard H. and Cass R. Sunstein, Nudge: Improving Decisions About Health, Wealth and Happiness, New Haven: Yale University Press, 2008.

Slow Medicine Recommended Movies on Aging

The Trip to Bountiful (1985, Peter Masterson)http://www.imdb.com/title/tt0090203/

The Company of Strangers OR Strangers in Good Company (1991, Cynthia Scott)http://www.imdb.com/title/tt0102993/

Everybody’s Fine (1990, Giuseppe Tornatore)http://www.imdb.com/title/tt0100681/

Wrestling Ernest Hemingway (1993, Randa Haines)http://www.imdb.com/title/tt0108596/

Tuesdays with Morrie (1999, Mick Jackson)http://www.imdb.com/title/tt0207805/

The Notebook (2004, Nick Cassavetes)http://www.imdb.com/title/tt0332280/

Mrs. Palfrey at the Claremont (2005, Dan Ireland)http://www.imdb.com/title/tt0421229/

Away From Her (2006, Sarah Polley)http://www.imdb.com/title/tt0491747/

The Savages (2007, Tamara Jenkins)http://www.imdb.com/title/tt0775529/

Young at Heart (2007, Stephen Walker, Sally George)http://www.imdb.com/title/tt1047007/

Up (2009, Pete Docter, Bob Peterson)http://www.imdb.com/title/tt1049413/