The perils of parenting… and iPods… and texting while driving…

My granddaughter’s birthday is today. She’s 19. A gifted art student, a remarkably grounded, neat kid. That’s the good news.

The bad news is that this afternoon she totaled her car.

The further good news is that she’s okay, and she didn’t hurt anyone else. But it was her fault. I understand the music was playing customarily loud; I certainly wouldn’t be surprised if she had been texting a friend.

The really bad news is that I don’t imagine either of the above behaviors will change.

In 2008, the latest year for which a lot of data has been collected and digested, some 3,500 teens between the ages of 15 and 19 died in car wrecks. About 10 times that many wound up in emergency rooms, but survived. The 15 to 24 age group accounts for 14% of the population, but it accounted for 30% of the costs of motor vehicle injuries ($19 billion) among males, and 28% ($7 billion) among females. Nobody knows how many of the young drivers causing those accidents were texting their friends at the time — cell phones tend to fly out the window, although many of them have survived to incriminate people who murdered other people during casual conversation. There’s a very popular YouTube video that ought to cure you; my granddaughter has seen it.

A few months ago I was driving my granddaughter to catch the BART train back to campus, fairly late one night, when I committed a minor traffic violation under the immediate gaze of a San Francisco policewoman. During the interminable length of time it took for the policewoman to sit in her car studying her computer I did a lot of beating on the steering wheel, ranting about how this would ruin our insurance, how I hadn’t had a ticket in decades, how furious I was with myself for a dumb move. Eventually the policewoman returned, congratulated me on my excellent driving record, and said, “I’m going to give you a break this time, Ms. Johns…” and my granddaughter and I exhaled.

For the next few minutes we talked about my driving record. I said at least some of it has to relate to the fact that I do not talk on the phone while driving and I do not text while driving, and I like soft music (actually, I don’t think I mentioned the music business.) Those, however, are not dots one is interested in connecting if one is 18 years old… or any age, probably, coming from a little-old-lady driver who just got off lucky.

My greatly beloved granddaughter said she often texts while driving. “Everybody does,” she said.

Catholic bishops mandate treatment to keep comatose patients alive

Catholic hospitals across the country face a new mandate this year to provide life-sustaining treatment to comatose patients regardless of the wishes of those patients and/or their families, and even when there is no hope of recovery.

The U.S. Conference of Catholic Bishops issued the directive Nov. 17 to the more than 1,000 church-affiliated hospitals and nursing homes in the United States and to all Catholic doctors and nurses. Invoking a 2004 speech by Pope John Paul II, the bishops said Catholics must provide nutritional assistance to patients with “presumably irreversible conditions … who can reasonably be expected to live indefinitely if given such care.”

A previous directive let Catholic hospitals and doctors decide whether the burdens on the patient outweighed the benefits of prolonging life. The bishops said the new policy was guided by “Catholic teaching against euthanasia” and by John Paul’s observation that providing food and water “always represents a natural means of preserving life, not a medical act.”

The issue of whose wishes will be observed — the patient’s or the bishops’ — is certain to be raised. And in the case of a comatose patient, having someone else to advocate in one’s behalf will be critical.

Catholic hospital officials say the November decree isn’t rigid and leaves room for accommodating patients’ wishes. But the bishops’ language appears to conflict with a hospital’s legal duty to follow a patient’s instructions to withdraw life support, as expressed in an advance written directive or by a close relative or friend who knows the patient’s intentions.

Courts have ordered hospitals to disconnect feeding tubes when an unconscious patient’s wishes were clearly established. The best-known case involved Terri Schiavo, the Florida woman who died in 2005 after 15 years in a coma and unsuccessful attempts by her parents and Republicans in Congress to keep her alive.

The decree itself does not require life-sustaining care that would be “excessively burdensome for the patient” or would cause “significant physical discomfort.” If those exemptions don’t apply, a hospital will send a patient elsewhere rather than violate his or her expressed wishes, the (Catholic hospitals) organizations said.

The Catholic Health Association of the United States, which represents both hospitals and nursing homes, said a facility’s ethics committee would probably meet with the doctor and the patient’s representative to “explore the alternatives” whenever a patient’s decision to withdraw life support clashed with Catholic doctrine.”In some instances, this might include the transfer of the patient to another facility,” the association said.

Considering the number of Catholic hospitals, nursing homes, doctors and nurses under the bishops’ directive and the number of people who would not choose to spend their final weeks and months hooked up to tubes and wires, ethics committees are going to be very busy. It is hard to make sense of this across-the-board imposition of one religion’s views on countless patients whose own wishes may differ.

New Catholic mandate on comatose patients.

Montana court affirms aid in dying

Montana has become the third U.S. state to give terminally ill adults the right to choose aid in dying. The decision, which came from the State Supreme Court on New Year’s Eve, 2009, was handed down by the highest body for state issues and thus cannot be appealed. The other two states honoring a patient’s wish to choose aid in dying are Oregon, which has successfully maintained its Death with Dignity legislation for more than a decade, and Washington, which passed a similar law last year.

The Montana ruling came too late for one plaintiff.

Roberta King, of Missoula, the daughter of plaintiff Bob Baxter, said, “My father died without the peace and dignity he so dearly wanted for himself and others. He feared when he filed this lawsuit that he would not live long enough to benefit from it. I’m sure he would be deeply gratified that other terminally ill Montanans will have the choice and comfort that aid in dying affords them.”

The Montana case was backed by Compassion and Choices, with C&C Legal Director Kathryn Tucker serving as co-counsel to the plaintiffs/respondents. (Full disclosure: I serve on the board of Compassion and Choices’ Northern California chapter.) The decision gave Tucker a major boost for her New Year’s celebrations. She was quoted on New Year’s Day as saying,

Montanans trapped in an unbearable dying process deserve, and will now have, this end-of-life choice. This is the first state high court to find protection of this choice, and makes clear that in Montana, patients are able to make this choice and physicians can provide this care without risking sanction.”

Others, including medical professionals and critically ill patients who invested long hours in seeking the new ruling, were equally gratified.

Dr. Stephen Speckart, a Missoula cancer specialist and a plaintiff in the lawsuit, said, “This decision affirms that a terminal patient’s fundamental right to self-determination will guide end-of-life health decisions. I regularly treat patients dying from cancer, and many of these deaths are slow and painful. Terminal patients will no longer be forced to choose between unrelenting pain and an alert mental state as they approach the end of their lives from terminal diseases. The comfort this brings to their last days can have an immeasurable benefit.”

Missoula attorney Mark Connell, who argued the case to the Supreme Court on behalf of the plaintiff physicians and patients, described the decision as “a victory for individual rights over government control.” Connell added: “The Montana Supreme Court has now recognized that, where intensely personal and private choices regarding end-of-life care are involved, Montana law entrusts those decisions to the individuals whose lives are at stake, not the government. I know Bob Baxter would be very pleased that the court has now reaffirmed that these choices should be left to the terminally ill people in our state.”

Steve Johnson, 71, of Helena, who is terminally ill with brain cancer, hailed the decision and asked the Montana medical profession to provide patients like himself with aid in dying. “I approach the end of my life with a clear mind, and I would like to work with my doctor to minimize the pain and maximize the peacefulness in my dying. I would like my physician to be able to respect and honor my choice to die with dignity. Adults like myself should have the option, if terminally ill, to request physician aid in dying. It’s only compassionate to minimize unnecessary suffering at the end of life, and to let me make the choice about how much suffering to endure, based on my own values and beliefs,” said Johnson.

The movement had widespread support across the state.

Montana State Sen. Christine Kaufmann, Rep. Dick Barrett and twenty-nine other state legislators; the American Medical Women’s Association, the American Medical Students Association, and a coalition of Montana clinicians; the American College of Legal Medicine; the American Civil Liberties Union of Montana; the Montana Human Rights Network; the Northwest Women’s Law Center; terminal patients’ surviving family members; Montana religious leaders; and Montana’s leading constitutional law experts had urged the Court to find in favor of the terminal patient’s right to receive aid in dying from their physicians.

According to Compassion and Choices president Barbara Coombs Lee, the battle for “the right to choose a humane and compassionate death will continue. (We) encourage terminally ill patients to call 800 247-7421 if they would like information about aid in dying, or suggestions on how to open a dialogue with their physician and loved ones.”

Goodbye to all that — & hello 2010

It’s hard to mourn the passage of 2009. Jobless friends struggled to survive while our own family income took a dive. Gay friends watched meanness triumph over decency in equality battles. Friends of many stripes lamented choices made by the president we elected with unrealistically high hopes. And my hometown paper this morning lists, among the top stories of the year, teenage gang rape, government insolvency and a bunch of senseless killings.

Other front pages aren’t much different: my second-favorite city winds up the year in the red and worried about the shadow of 9/11 (New York Times.) Murder and assault — specifically assault compounded by injustice — are among today’s concerns in Chicago. And a couple of other former hometown papers lead off the year’s last day with stories of car crashes, shootouts (Atlanta Journal Constitution) and a tragic, child-abandoning, now dead, alcoholic mom (Richmond Times-Dispatch). Plus another doozy about four or five hundred dead animals found in one house — and that happened in Philadelphia.

Optimism, these days, is a full-time job.

But hey. We’re inching toward health reform. Umar’s bomb didn’t go off.  Some of those bad guys (above) went to jail, and a few good guys who’d been jailed as bad guys for a very long time got out of jail thanks to the Innocence Project.  And even if the best we can do for employment optimism is note that the rate of jobs lost is getting smaller — can the country’s jobless find hope in that? — the jobless recovery seems to be happening. Surely jobs will follow.

Plus: even if we don’t like all of his choices and decisions, we have an articulate president who comes across, still, as thoughtful and decent — and doesn’t make you cringe when you see him on TV. There’s hope.

And True/Slant, which you’d never heard of this time last year, is closing in on a million readers.

Happy New Year from the Boomers and Beyond page.

Your latte or your life

At last, an addiction I can be proud of. Having given up nicotine, alcohol and sin in general over the years, I was beginning to despair about the remaining unbreakable habits:  sugar, butterfat… and caffeine.  But now, suggests Wall Street Journal health writer Melinda Beck, caffeine might just be putting a little distance between Alzheimer’s and me. It might not be an anti-dementia guarantee, and it could have a few downer side effects, but still. A ray of sunshine on the addiction scene.

To judge by recent headlines, coffee could be the latest health-food craze, right up there with broccoli and whole-wheat bread.

But don’t think you’ll be healthier graduating from a tall to a venti just yet. While there has been a splash of positive news about coffee lately, there may still be grounds for concern.

  • Cancer: Earlier studies implicating coffee in causing cancer have been disproven; may instead lower the risk of colon, mouth, throat and other cancers.
  • Heart disease: Long-term coffee drinking does not appear to raise the risk and may provide some protection.
  • Hypertension: Caffeine raises blood pressure, so sufferers should be wary.
  • Cholesterol: Some coffee—especially decaf—raises LDL, the bad kind of cholesterol.
  • Alzheimer’s: Moderate coffee drinking appears to be protective.
  • Osteoporosis: Caffeine lowers bone density, but adding milk can balance out the risk.
  • Pregnancy: Caffeine intake may increase the risk of miscarriage and low birth-weight babies.
  • Sleep: Effects are highly variable, but avoiding coffee after 3 p.m. can avert insomnia.
  • Mood: Moderate caffeine boosts energy and cuts depression, but excess amounts can cause anxiety.

So let’s see. My bone reports have actually upscaled recently, so all that butterfat and a few bone meds are outpacing the latte. I can fall asleep midway through a cappuccino, and I don’t have time to be depressed. Unlikely to get pregnant. Addiction situation looks better and better. Further insight comes from Duke University Medical Center psychophysiologist Jim Lane, who’s been studying the effects of caffeine for more than 25 years, and from a distinguished addiction psychiatrist (I wonder if I should volunteer for a study) at Vanderbilt University.

“When I went to medical school, I was told that coffee was harmful. But in the ’90s and this decade, it’s become clear that if you do these studies correctly, coffee is protective in terms of public health,” says Peter R. Martin, a professor of psychiatry and pharmacology at Vanderbilt University and director of the school’s Institute for Coffee Studies, founded in 1999 with a grant from coffee-producing countries.Still, many researchers believe that the only way to draw firm conclusions about something like coffee is through experimental trials in which some subjects are exposed to measured doses and others get a placebo, with other variables tightly controlled. When that’s been done, says Duke’s Dr. Lane, “the experimental studies and the [observational] studies are in very sharp disagreement about whether caffeine is healthy or not.”

Harmful Effects

His own small, controlled studies have shown that caffeine—administered in precise doses in tablet form—raises blood pressure and blood-sugar levels after a meal in people who already have diabetes. Other studies have found that caffeine and stress combined can raise blood pressure even more significantly. “If you are a normally healthy person, that might not have any long-term effect,” says Dr. Lane. “But there are some groups of people who are predisposed to get high blood pressure and heart disease and for them, caffeine might be harmful over time.”

[HEALTHCOLfront]

Epidemiologists counter that such small studies don’t mirror real-world conditions, and they can’t examine the long-term risk of disease.

The debate goes on. Do people remember how many cups they drink? How big is your mug? How random is your study? Did your ancestors have a history of — uh, oh, my parents met and married in Brazil where I was born. Maybe that’s where it all started.

I will welcome your comments on caffeine addictions; they will be compiled over a take-out tall extra-foamy latte.

Seeking Coffee’s Benefits to Health – WSJ.com.


End-of-year look at end-of-life issues

Two end-of-year stories offer stark insights into end-of-life issues in the U.S., one from a purely financial perspective, the other purely about compassion. Between the two, the conflicted American way of dying comes into focus.

First the finance. The Wall Street Journal of December 30 features a front page story by Laura Saunders about wealthy families coming to grips with the disappearance, thanks to a quirk of Congress, of the estate tax beginning January 1, 2010. It will only disappear for a year, and in 2011 it will return at a higher rate with lower exemption. For those approximately 5,500 super-rich taxpayers to whom this tax applies, a lot of money is at stake. Presumably if a member of one of these families is now near death every possible measure will be taken to keep him or her alive into the new year and presumably that will be done for the best of reasons. But imagine the struggles involved if someone is near death this time next year, and his or her heirs stand to benefit in the millions if that death happens before January 1st rather than soon after. An altogether new meaning will have to be added to “letting go.” Not something one really wants to think through.

But the last two sentences of the WSJ article demonstrate how extensively the scenario is indeed being thought through, not from the heir’s point of view but from the soon-to-be-departed:

The situation is causing at least one person to add the prospect of euthanasia to his estate-planning mix, according to Mr. (Andrew) Katzenstein (a lawyer with) Proskauer Rose (LLP in Los Angeles.) An elderly, infirm client of his recently asked whether undergoing euthanasia next year in Holland, where it’s legal, might allow his estate to dodge the tax.

His answer: Yes.

However hard we might try to eliminate costs (and cost/benefit ratios) from considerations of end-of-life care and decision-making, they are here to stay and sure to remain complex. Another complexity — and this one should not be as difficult as it continues to be — surrounds the subject of palliative care. Palliative care is simply comfort care. It means, do everything possible to insure that a dying person might go about his or her dying with as little pain and anguish as humanly, medically possible.  A long, careful look into the issue is in the New York Times most recent “Months to Live” series article, “Hard Choice for a Comfortable Death” by health writer Anemona Hartocollis.

In almost every room people were sleeping, but not like babies. This was not the carefree sleep that would restore them to rise and shine for another day. It was the sleep before — and sometimes until — death.

In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream on Long Island, the patients were sleeping because their organs were shutting down, the natural process of death by disease. But at least one patient had been rendered unconscious by strong drugs.

The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart failure and kidney problems, was brought from home by his wife and son, who were distressed to see him agitated, jumping out of bed and ripping off his clothes. Now he was sleeping soundly with his mouth wide open.

“Obviously, he’s much different than he was when he came in,” Dr. Edward Halbridge, the hospice medical director, told Mr. Oltzik’s wife. “He’s calm, he’s quiet.”

Mr. Oltzik’s life would end not with a bang, but with the drip, drip, drip of an IV drug that put him into a slumber from which he would never awaken. That drug, lorazepam, is a strong sedative. Mr. Oltzik was also receiving morphine, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. In so doing, it can hasten death.

Mr. Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counseling, physicians like Dr. Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.

Writer Hartocollis covers in thoughtful detail the long, sometimes conflicted process through which the medical team and the patient’s family arrived at his eventual, peaceful death. The article looks at the multiplicity of issues that cry out for reasoned public dialogue — palliative care, physician aid in dying, end-of-life choice, family decision-making — that have been raised on this page in recent months and will be back again. It’s a story worth reading in full.

And meanwhile, the beginning of the year is a fine time to get your advance directives and other documents completed and to have those conversations with friends and loved ones that keep you from becoming another Terri Schiavo. Getting this done is one great way to put dying behind you and go about the business of living for a happy new year.

Months to Live – Hard Choice for a Comfortable Death – Sedation – Series – NYTimes.com.

Thank-you notes come due

E-mails are efficient, text messages — God help us — are here to stay, but the handwritten thank-you note is not dead yet. If Geoffrey Parker and I have anything to do with it, furthermore, the handwritten note will survive and prosper. Parker’s commitment to this disappearing art form was outlined in a Wall Street Journal report by Cheryl Lu-Lien Tan. If you want to make points with gift-givers, you might note his words of wisdom.

During the holidays, Geoffrey Parker, branding consultant for Parker Pen Co. and great-grandson of its founder, George S. Parker, is careful not to overlook what he calls a ‘critical’ aspect of the gift-giving season: thank-you notes.

‘It’s common courtesy,’ he says. ‘If someone does something for me, I need to acknowledge that.’ Mr. Parker sometimes thanks a gift-giver or party host with a phone call, email or text message. But he believes that these modes are ‘insufficient’ and always follows up with a handwritten message. ‘As these modern electronic devices become more common and overused, they become cheap,’ he says.

And more power to Mr. Parker. A phone call or an e-mail message might acknowledge your gratitude, but a handwritten note has soul. Quick: think of a piece of paper with words written on it, addressed to you, by someone of your acquaintance. Some little shred ties those words to that person, doesn’t it? Handwriting used to serve that purpose.

A quick check with several teacher friends turned up no one who could recall the time when cursive was routinely taught throughout the fourth grade year (though you can now learn to write online.) By fourth grade today every student on the planet knows how to text in abbreviated expletives. But nothing conveys a message — expletive or smiley face — like a handwritten note. You will be forgiven if you use a ball point pen, though Parker prefers a fountain pen with a broad nib and fountain pens can emote better than anything else. The flourish that such an implement can create — think John Hancock before he got commercialized — used to be able to paint eloquent pictures in words. My father (broad nib, dark blue ink) favored x’s at the end of his sentences, but when he left off with a dash you knew you had done something fine.

Today, a thank-you note is also an investment. But go ahead, spend the 44 cents, drop a line. Your appreciation will be appreciated.

The cost of trying to live forever

Why is this not an encouraging word? In a front page article, part of a Months to Live series,  New York Times writer Reed Abelson leads with a glimpse into the Ronald Reagan U.C.L.A. Medical Center, a top-rated academic hospital noted for extensive, aggressive end-of-life care (and very high costs):

‘If you come into this hospital, we’re not going to let you die,’ said Dr. David T. Feinberg, the hospital system’s chief executive.

Feinberg’s commitment to “success” might be admirable, but the statement is patently false; people die at U.C.L.A. Medical Center. This is what people do: we die. Until this culture gets its act together on that subject our health care system — whatever the reform bill eventually looks like — will continue to flounder.

Difficult as it is to talk dollars when you’re talking lives, the issue of cost has to be factored in. There are only so many dollars, and there are countless lives needing care those dollars can buy: infants, children, young adults, boomers, elderly. In each of those care-needing groups, some die.  Feinberg’s philosophy somewhere has to encounter reality.

…that ethos (keep testing, treating, keeping alive no matter what) has made the medical center a prime target for critics in the Obama administration and elsewhere who talk about how much money the nation wastes on needless tests and futile procedures. They like to note that U.C.L.A. is perennially near the top of widely cited data, compiled by researchers at Dartmouth, ranking medical centers that spend the most on end-of-life care but seem to have no better results than hospitals spending much less.

Listening to the critics, Dr. J. Thomas Rosenthal, the chief medical officer of the U.C.L.A. Health System, says his hospital has started re-examining its high-intensity approach to medicine. But the more U.C.L.A.’s doctors study the issue, the more they recognize a difficult truth: It can be hard, sometimes impossible, to know which critically ill patients will benefit and which will not.

That distinction tends to get lost in the Dartmouth end-of-life analysis, which considers only the costs of treating patients who have died. Remarkably, it pays no attention to the ones who survive.

No one, not the doctors, not the patients, not the best crystal ball reader around can guarantee that this patient will die or that patient will live. If there is a good chance a patient will survive — and it would be nice to add “with a reasonable quality of life” here — everything possible, and affordable, certainly should be done. Abelson’s carefully balanced article details the arguments for going to extraordinary lengths to save lives, as well as the arguments to draw the line on end-of-life expenses.

According to Dartmouth, Medicare pays about $50,000 during a patient’s last six months of care by U.C.L.A., where patients may be seen by dozens of different specialists and spend weeks in the hospital before they die.

By contrast, the figure is about $25,000 at the Mayo Clinic in Rochester, Minn., where doctors closely coordinate care, are slow to bring in specialists and aim to avoid expensive treatments that offer little or no benefit to a patient.

“One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical,” Peter R. Orszag, the White House budget director and a disciple of the Dartmouth data, has noted. “We can no longer afford an overall health care system in which the thought is more is always better, because it’s not.”

By some estimates, the country could save $700 billion a year if hospitals like U.C.L.A. behaved more like Mayo. High medical bills for Medicare patients’ final year of life account for about a quarter of the program’s total spending.

So…. to spend that $25,000/$50,000 or not to spend? Unless we the people somehow face the reality that living forever is not a human option, the dilemma will continue.

The benefits of coming to terms with non-optional dying could be huge. We could focus on quality living. On palliative care and hospice care and end-of-life peace and comfort. Advances in palliative care now make it possible for most of us to spend final months at home (or in special hospital rooms), in comfort, surrounded by loved ones; given the choice, would you prefer a few weeks or months in a bright-lit sterile room with a lot of tubes and wires keeping you alive? U.C.L.A. now offers the choice of palliative care. Not everyone in charge, however, is convinced.

Dr. Bruce Ferrell, who helps lead the palliative care program, recalls a patient two years ago who got a liver transplant but developed serious complications afterward and remained in the hospital for a year. “He had never, ever been told that he would have to live with a ventilator and dialysis,” Dr. Ferrell said. “He was never told that this is as good as it’s going to get.”

Dr. Ferrell talked with the patient about whether he might want to leave the intensive-care unit to go home and receive hospice care. But when the surgeon overseeing the case found out, he was furious.

“We do not use the h-word” — hospice — “on my patients,” the surgeon told Dr. Ferrell. “Don’t ever come back.”

The patient chose to leave.

But lately, Dr. Ferrell says, more of the transplant surgeons appreciate the value of what he is trying to do.

“We’re not the bad guys,” he said. “We offer options.”

We the people would do well to quit being the bad guys. To quit behaving as if death were always preventable. We could learn about the options to spending all those thousands of dollars on exhaustive, often futile treatment. We could talk about what we would or would not want for ourselves, write things down, make choices.

If more of us would do that for ourselves, the House and Senate wouldn’t have such a time trying to do it for us.