Humainologie creative dialogue Wednesday November 24 on Hope, Courage, and Mortality

One Art

The art of losing isn’t hard to master; so many things seem filled with the intent to be lost that their loss is no disaster.

Lose something every day. Accept the fluster of lost door keys, the hour badly spent. The art of losing isn’t hard to master.

Then practice losing farther, losing faster: places, and names, and where it was you meant to travel. None of these will bring disaster.

I lost my mother’s watch. And look! my last, or next-to-last, of three loved houses went. The art of losing isn’t hard to master.

I lost two cities, lovely ones. And, vaster, some realms I owned, two rivers, a continent. I miss them, but it wasn’t a disaster.

—Even losing you (the joking voice, a gesture I love) I shan’t have lied. It’s evident the art of losing’s not too hard to master though it may look like (Write it!) like disaster.

- Elizabeth Bishop

On Wednesday November 24, our topic is Hope, Courage, and Mortality. I have appended herewith my synopsis of Atul Gawande’s book Being Mortal: Medicine and What Matters in the End. In the synopsis (always limited to about 1,500 words) I could not include the details of the case histories provided in the book, which are very helpful for understanding in practice how people have been able to cope with end-of-life challenges. The most inspiring parts of the book for me were about others, in the prime of life, who have used their imagination to change the way we think about old age and how to make the experience as good as possible. Two examples are Keren Brown Wilson (who created the original concept of assisted living) and Dr. Bill Thomas (who transformed a nursing home of which he had become the medical director). The synopsis gives a brief account of those stories. However, I cannot resist providing more information here.

Dr Thomas https://en.wikipedia.org/wiki/William_H._Thomas_(physician) “was by temperament a serial entrepreneur, though without money,” writes Gawande. He and his wife cofounded the Pioneer Network, “a kind of club for the growing number of people committed to the reinvention of elder care.” https://www.pioneernetwork.net/better-together-2021-live-events/

Later, around 2000, he decided to build a nursing home himself and created what he called the Green House https://en.wikipedia.org/wiki/Green_House_Project which led to the National Green House Replication Initiative, supported by a charitable foundation that enabled more than 150 Green Houses in 25 states to be constructed. “All Green Houses are small and communal. None has more than twelve residents.”

As dialogue artists you too – like Keren Brown Wilson and Dr. Bill Thomas – are able to see opportunity in every difficulty. Here are some good questions on our topic of Hope, Courage, and Mortality:

1. Please share your wisdom gained from a particularly difficult experience you went through. How did you survive? What surprised you about it? Did you benefit from the experience in any way?

2. Each day is a gift, and the gift has to be used on that day. How do you make it through the day? How do you make the most of each day?

3. Is there something – a particular philosophy or religion, for example – that sustains you in the face of your own awareness of mortality? What thoughts about old age and mortality have you had that you could share with us?

Here is the Zoom link provided by Shinobu::

Topic: Humainologie Dialogue Session Time: Nov 24, 2021 06:30 PM Mountain Time (US and Canada) Every week on Wed, until Dec 29, 2021, 9 occurrence(s) Join Zoom Meeting https://us02web.zoom.us/j/89600374916?pwd=OXg2dkF4NEtsMmNzSkdRdW1kdUV5UT09 Meeting ID: 896 0037 4916 Passcode: 12345

Arthur

Book: (Atul Gawande) Being Mortal: Medicine and What Matters in the End (2014)

Many people want to have a long life but are reluctant to think about what happens in “the end.” Atul Gawande (born 1965), a surgeon at the Brigham and Women’s Hospital in Boston, suggests we should think about it, and has written this book to help. It became a #1 New York Times bestseller. In the Introduction, he writes, “Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.” Our reluctance to accept it and talk about it has gotten us into trouble. “The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions – nursing homes and intensive care units – where regimented, anonymous routines cut us off from all the things that matter to us in life. …Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.”

The book interweaves the instructive details of individual cases; historical trends and events such as the creation of the first “retirement community” in 1960 and of “assisted living” in the 1980s; and emerging basic principles for better ways of dealing with the challenges. Chapter 1, “The Independent Self,” describes the dramatic contrast between how old age and the end of life were experienced 150 years ago, and how they are experienced today. ”The veneration of elders may be gone, but not because it has been replaced by the veneration of youth. It’s been replaced by veneration of the independent self.” The title of Chapter 2, “Things Fall Apart,” refers to the cumulative effects of aging on the various organs of our bodies. Centuries ago, death was more familiar to people of all ages than it is today. Close proximity to someone who is dying is not a common experience for young people today, most of whom take it for granted they will have a long life. The cumulative effects of aging on cardiovascular and other systems eventually leads to a terminal event. A physician asked to help is faced with a complex situation. Geriatrics is an endangered specialty, yet an incredibly important one as people of advanced age represent increasing percentages of the population. The geriatrician must typically deal with a raft of problems - many of which will never have a satisfactory solution – that an elderly person presents with. Other medical specialists want simple problems they can fix. We need more geriatricians, and we are getting fewer. A possible solution is good geriatric training for family physicians and others.

Chapter 3, “Dependence,” reminds us that if we exercise, eat healthy, and so on, “people can often live and manage a very long time.” However, there comes a time when we can no longer manage. How can we cope? An 87-year-old retired geriatrician had found purpose in caring for his wife, yet he was often despondent, and told the author, “I try not to think too far ahead. I don’t think about next year. It’s too depressing. I just think about next week.” Dependence is anathema to some people. An historic case is that of an 83-year-old man who adamantly refused to leave his home near the foot of a volcano (Mount Saint Helens in Washington state). It erupted in May 1980. Posthumously, he became a local hero, with a monument and a TV movie made about him. Nursing homes evolved in the mid-twentieth century. They provided safety from dangers such as falling that older people face. But people want more than safety. One nursing home resident said that what she missed most were “friendship, privacy, and a purpose to her days.” The author writes, “but it seems we’ve succumbed to a belief that, once you lose your physical independence, a life of worth and freedom is simply not possible.” Therefore, the goal that matters to most nursing home residents is this: “how to make life worth living when we’re weak and frail and can’t fend for ourselves anymore.” Chapter 4, “Assistance,” describes the importance of being able to make your own choices even late in life, and how things have evolved that enhance or undermine that autonomy. In the 1980s, Keren Brown Wilson moved a step closer to her vision of a place where the elderly “could live with freedom and autonomy no matter how physically limited they became.” After a PhD program in gerontology, she and her husband, a sociologist, opened the first “’living center with assistance’ for the elderly” in Portland, Oregon in 1983. Despite initial resistance to the idea, a careful tracking of health and life satisfaction of tenants revealed (according to a 1988 publication of the findings) that the assisted living program was a huge success. Life satisfaction had improved, health was maintained and some aspects of health such as cognitive functioning had improved. The assisted living concept took off, but other priorities – notably a corporate mindset and the profit motive – intervened, and the original purpose of assisted living was undermined. Wilson tried to reverse the corporate takeover, but it was a losing battle. Gawande summarizes the outcome by quoting Wilson, “I love it when assisted living works,” and then adding his own comment, “It’s just that in most places it doesn’t.”

In Chapter 5, “A Better Life,” we find the story of the transformative effect Dr. Bill Thomas had on the Chase Memorial Nursing Home in the small town of New Berlin in upstate New York. Four out of five of the residents of the home had some form of cognitive disability, such as Alzheimer’s disease and about half of them had physical disability. Dr. Thomas had become the medical director and aware of what he called “the Three Plagues of nursing home existence: boredom, loneliness, and helplessness.” He brought two dogs, four cats, and one hundred parakeets to the nursing home, and transformed the day-to-day experience of the residents. The result was an apparent miracle, with incredible improvement in the lives of residents and staff. Thomas attributed the effects to a “fundamental human need for a reason to live.” Without a reason to live that is outside the little self, the human spirit languishes (as it does in so many nursing homes). “Medical professionals concentrate on repair of health, not sustenance of the soul,” Gawande writes. He refers to the application of this approach to care of the aged as an experiment and writes “That experiment has failed.”Chapter 5 goes on to describe an astonishing diversity of initiatives in care of the aged that have succeeded, concluding “…we have at last entered an era in which an increasing number of [the professionals and institutions] believe their job is not to confine people’s choices in the name of safety, but to expand them, in the name of living a worthwhile life.” In yet another inspiring element of Chapter 5, Gawande refers to an essay written in 1986 by Ronald Dworkin on the real value of autonomy. Autonomy is not fulfilling in and of itself; instead, we need enough autonomy “to be the authors of our lives.”

Chapter 6 is entitled “Letting Go.” The situations and conversations described here are extremely difficult, fraught with uncertainty for example about whether treatment with a slim chance of cure is worth the large risk of making everything worse. Perhaps the most important message in this chapter is that having honest, ongoing conversations with the terminally ill patient makes all the difference. Palliative care specialists know how to do this. A landmark 2010 study showed that when a palliative care specialist was involved in their care as well as an oncologist, patients chose to stop therapy sooner, experienced less suffering, and lived 25% longer! Gawande suggests a principle that “seems almost Zen: you live longer only when you stop trying to live longer.” Chapter 7, “Hard Conversations,” again emphasizes the benefits of taking the time to carry out skillful, ongoing conversations with those who are losing so much that had made life worth living. The eighth and final chapter is entitled “Courage.” Atul Gawande suggests a possible definition: “Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.” Gawande then suggests two kinds of courage needed in aging and sickness. “The first is the courage to confront the reality of mortality – the courage to seek out the truth of what is to be feared and what is to be hoped.” That kind of courage is difficult, but the second kind is even more difficult - ”the courage to act on the truth we find. The problem is that the wise course is so frequently unclear. …One has to decide whether one’s fears or one’s hopes are what should matter most.” In his Epilogue to the book, Gawande suggests four questions to ask the person struck down with serious ailments: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?