Bruce Grierson in the NYT Magazine:

One day in the fall of 1981, eight men in their 70s stepped out of a van in front of a converted monastery in New Hampshire. They shuffled forward, a few of them arthritically stooped, a couple with canes. Then they passed through the door and entered a time warp. Perry Como crooned on a vintage radio. Ed Sullivan welcomed guests on a black-and-white TV. Everything inside — including the books on the shelves and the magazines lying around — were designed to conjure 1959. This was to be the men’s home for five days as they participated in a radical experiment, cooked up by a young psychologist named Ellen Langer.

The subjects were in good health, but aging had left its mark. “This was before 75 was the new 55,” says Langer, who is 67 and the longest-serving professor of psychology at Harvard. Before arriving, the men were assessed on such measures as dexterity, grip strength, flexibility, hearing and vision, memory and cognition — probably the closest things the gerontologists of the time could come to the testable biomarkers of age. Langer predicted the numbers would be quite different after five days, when the subjects emerged from what was to be a fairly intense psychological intervention.

Pam Belluck in the NYT:

“We think it’s really important to incentivize this kind of care,” said Dr. Barbara Levy, chairwoman of the A.M.A. committee that submits reimbursement recommendations to Medicare. “The idea is to make sure patients and their families understand the consequences, the pros and cons and options so they can make the best decision for them.”

Now, some doctors conduct such conversations for free or shoehorn them into other medical visits. Dr. Joseph Hinterberger, a family physician here in Dundee, wants to avoid situations in which he has had to decide for incapacitated patients who had no family or stated preferences.

Recently, he spent an unreimbursed hour with Mary Pat Pennell, a retired community college dean, walking through advance directive forms. Ms. Pennell, 80, who sold her blueberry farm and lives with a roommate and four cats, quickly said she would not want to be resuscitated if her heart or lungs stopped. But she took longer to weigh options if she was breathing but otherwise unresponsive.

“I’d like to be as comfortable as I can possibly be,” she said at first. “I don’t want to choke, and I don’t want to throw up.”

With reimbursement, “I’d do one of these a day,” said Dr. Hinterberger

There are two things I care passionately about, and believe american culture (western culture generally) have wrong; education, and death. Here is a great piece on the latter. This is not something we can fix through legislation. (see: Death councils). It will have to be a cultural shift.

Atul Gawande in The New Yorker:

A few days before Thanksgiving, she had another CT scan, which showed that the pemetrexed—her third drug regimen—wasn’t working, either. The lung cancer had spread: from the left chest to the right; to the liver; to the lining of her abdomen; and to her spine. Time was running out.

This is the moment in Sara’s story that poses a fundamental question for everyone living in the era of modern medicine: What do we want Sara and her doctors to do now? Or, to put it another way, if you were the one who had metastatic cancer—or, for that matter, a similarly advanced case of emphysema or congestive heart failure—what would you want your doctors to do?

The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the country’s long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.

And the hour long documentry on Frontline is here. Trailer for that:

Sandeep Jauhar in the NYT:

Of all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients. When you reduce the volume of air per breath, the only way to maintain ventilation is to breathe faster.

As our workdays have gotten busier, we doctors have had less time to devote to individual patients. An internist I know in private practice used to see 15 patients a day. “Now reimbursement is so low I have to see at least 30,” he told me. “If I stay in the room more than 10 minutes, my assistant will call me and tell me to hurry up.”

Racing through patient encounters, we practice with an ever-present fear that we will miss something, hurt someone and open ourselves up to legal (not to mention moral) liability. To cope with the anxiety, we start to call in experts for problems that perhaps we could handle ourselves if we had more time to think through a case. The specialists, in turn, order more tests, scans and the like.

And therein lies the sad irony of the health cost containment paradigm in this country. There is no more wasteful entity in medicine than a rushed doctor.

Finzi began musing on the facial feedback hypothesis, which holds that physical expression is an integral component of emotion. You can feel sad or angry without moving your face, but, the theory holds, those emotions will not be as strong or persist for as long if your face is not moving in the expected manner. Put another way, relative to emotion, the face and its muscles are a privileged area of the body. Whatever you do with your face transmits feelings back to your brain.

In 2003, Finzi treated several subjects suffering from moderate to severe depression with Botox, paralyzing the muscles in their brows that create expressions of sadness, anger, and fear. The results were astonishing.

Roger Angell in The New Yorker:

I’ve endured a few knocks but missed worse. I know how lucky I am, and secretly tap wood, greet the day, and grab a sneaky pleasure from my survival at long odds. The pains and insults are bearable. My conversation may be full of holes and pauses, but I’ve learned to dispatch a private Apache scout ahead into the next sentence, the one coming up, to see if there are any vacant names or verbs in the landscape up there. If he sends back a warning, I’ll pause meaningfully, duh, until something else comes to mind.

On the other hand, I’ve not yet forgotten Keats or Dick Cheney or what’s waiting for me at the dry cleaner’s today. As of right now, I’m not Christopher Hitchens or Tony Judt or Nora Ephron; I’m not dead and not yet mindless in a reliable upstate facility. Decline and disaster impend, but my thoughts don’t linger there. It shouldn’t surprise me if at this time next week I’m surrounded by family, gathered on short notice—they’re sad and shocked but also a little pissed off to be here—to help decide, after what’s happened, what’s to be done with me now. It must be this hovering knowledge, that two-ton safe swaying on a frayed rope just over my head, that makes everyone so glad to see me again. “How great you’re looking! Wow, tell me your secret!” they kindly cry when they happen upon me crossing the street or exiting a dinghy or departing an X-ray room, while the little balloon over their heads reads, “Holy shit—he’s still vertical!”

Watched “How to Die in Oregon” last night. Terribly flawed documentary, which I don’t recommend, but pretty brutal, and very convincing. We put cats and dogs down to avoid their unneeded suffering. Why not our parents?

Scott Adams on his blog:

My father, age 86, is on the final approach to the long dirt nap (to use his own phrase). His mind is 98% gone, and all he has left is hours or possibly months of hideous unpleasantness in a hospital bed. I’ll spare you the details, but it’s as close to a living Hell as you can get.

If my dad were a cat, we would have put him to sleep long ago. And not once would we have looked back and thought too soon.

See also this great news story: French couple, 86, slam ‘cruel’ law in suicide note

The couple, together since their teens, checked into the world-famous Hotel Lutetia on Thursday night and at some point in the night, they took medication designed to induce a painless death, according to Le Parisien. The couple also ordered breakfast to be delivered to their room in the morning to ensure they would be found quickly.

Georgette and Bernard were discovered dead, hand-in-hand, in their bed on Friday morning by a member of staff. Two letters were left by their bedside.

On Monday it was revealed that one of them contained a scathing attack on France’s prohibition of euthanasia.

Nathaniel Rich in the NYT Magazine:

Sommer was conducting research on hydrozoans, small invertebrates that, depending on their stage in the life cycle, resemble either a jellyfish or a soft coral. Every morning, Sommer went snorkeling in the turquoise water off the cliffs of Portofino. He scanned the ocean floor for hydrozoans, gathering them with plankton nets. Among the hundreds of organisms he collected was a tiny, relatively obscure species known to biologists as Turritopsis dohrnii. Today it is more commonly known as the immortal jellyfish.

Sommer kept his hydrozoans in petri dishes and observed their reproduction habits. After several days he noticed that his Turritopsis dohrnii was behaving in a very peculiar manner, for which he could hypothesize no earthly explanation. Plainly speaking, it refused to die. It appeared to age in reverse, growing younger and younger until it reached its earliest stage of development, at which point it began its life cycle anew.

Atul Gawande in The New Yorker:

Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?

Tim Doody in The Morning News:

For decades, the U.S. government banned medical studies of the effects of LSD. But for one longtime, elite researcher, the promise of mind-blowing revelations was just too tempting.

Carl Zimmer in the NYT:

For a century, doctors have waged war against bacteria, using antibiotics as their weapons. But that relationship is changing as scientists become more familiar with the 100 trillion microbes that call us home — collectively known as the microbiome.

“I would like to lose the language of warfare,” said Julie Segre, a senior investigator at the National Human Genome Research Institute. “It does a disservice to all the bacteria that have co-evolved with us and are maintaining the health of our bodies.”

This new approach to health is known as medical ecology. Rather than conducting indiscriminate slaughter, Dr. Segre and like-minded scientists want to be microbial wildlife managers.

Perri Klass, M.D. in the NYT:

In adult surgery, it is not routine to promise that someone can be with you in the operating room till you go to sleep, or to have family members a standard part of recovery room care. Many hospitals will let a family member stay overnight with an adult patient, but policies vary hospital by hospital, ward by ward.

“We accommodate family members much more in pediatrics,” Dr. Monash said. “We don’t have visiting hours where everyone has to leave.” [ … ] It seems to me we should be able to promise any hospital patient that a relative, a friend, can stay close at hand. We should be able to promise anyone going in for surgery that when she wakes up, someone familiar will be there.

Ken Murray:

Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds–from 5 percent to 15 percent–albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home.