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2011-12-07 22:52:48

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  1. 1. What does your author mean by the term “burn rate” when talking about Dr. Braun?
    “The burn rate for this living arrangement was phenomenal. After a few months, he moved to a nursing home and I became his physician.” Page 2
  2. 2. What does your author mean by “collective denial of aging”?
    “We have chosen to engage in collective denial of aging. We would prefer to believe that most people can skip old age altogether—proceeding directly from middle age to death, preferably dying in one’s sleep.” Page 6
  3. 3. What is evidence-based medicine in regard to the care for the elderly?
    “We need to change patients’ expectations of physicians, particularly in the area of health prevention and health maintenance, to better conform to what we have learned from evidence-based medicine.” Page 9
  4. 1. What is the PSA test and why is it not recommended for men over age 80?
    “but I also commented that screening for prostate cancer with a PSA test was not generally recommended for 80-year-olds. Too often, the test leads to a false-positive result: the PSA is elevated but the patient does not have cancer.” Page 15
  5. 2. Who is recommending that regular checkups be abandoned in favor of a more selective way of preventing disease?
    “American Medical Association” page 16
  6. 3. What is the primary reason for the annual visit to the doctor?
    “allows physician and patient to get to know each other…” page 17
  7. 4. For many years estrogen was considered a wonder drug for post-menopausal women. What findings were reported in 1998 about the effects of estrogen?
    “…they indicated that estrogen did not prevent heart attacks. On the contrary, it increased the risk of assorted medical problems…” page 22
  8. 5. The largest, most influential study of screening for breast cancer?
    included no women over the age of 64. Page 30
  9. 6. According to your author, we spend millions to test for and prevent diseases. What does she recommend we spend our money on instead?
    “What we should be trying to prevent are things like falls and social isolation, both of which can have extraordinary consequences for older people.” Page 34
  10. 1. What does your author mean by the following: “If hospitals are toxic to older people, why not try to treat them at home rather than administer antitoxins?”
    “if the benefit of the hospital—the presence of physicians and nurses 24 hours a day and of monitoring equipment—is also the source of the toxicity, then attempts at detoxification are destined to fail.” Page 41
  11. 2. Why does the medical profession tend not to consider intermediate care?
    “The psychological answer is that physicians are taught to target their efforts to prolonging life—beginning in medical school, where students are told that death is the enemy.” Page 46
  12. 3. What is the preference among most elderly for life-prolongation if the price is total dependence on other people?
    “nearly three-quarters of the older people interviewed said no to life-prolonging therapy.” Page 44
  13. 4. What is the goal of medicine as it is taught to physicians?
    “To stave off death” page 47
  14. 5. What is disease management?
    “…A strategy that involves ongoing monitoring of symptoms.” Page 57
  15. 6. How has the consumer movement reformed medical practices?
    “In general, the consumer movement has been a potent stimulus to reforming medical practices.” Page 61
  16. 2.What is meant by the phrase, “CPR not indicated”?
    “These institutions lay out a set of circumstances in which a physician can decide not to perform CPR if a patient’s heart stops and he isn’t breathing.” Page 76
  17. 1.What does your author mean by the phrase, “Pneumonia, is or at least can be the old person’s best friend.”
    Everyone had to die of something, and infection is often what turns a potentially protracted course of decline and disability into a brief terminal illness.” Page 64
  18. 3. What is PAS?
    Physician-assisted suicide (PAS) is a sanitized way of saying killing oneself with a physician’s help.” Page 83
  19. 4. Describe the founding of hospice.
    “Modern hospice care was born in 1967, when Dame Cicely Saunders founded St. Christopher’s Hospice in London. Her goal was to provide excellent symptomatic treatment for dying patients. Her insight was that patients who are not receiving curative treatment still deserve and need some kind of treatment.” Page 89
  20. 1. Why is Medicare a good program for robust elders and inadequate for frail people or those nearing the end of their life?
    “Medicare is an excellent program—for the most vigorous of older people… since it was originally designed to provide coverage for older patients with episodic, reversible diseases.” “It is profoundly inadequate for people who are frail or who are nearing the end of life… it favors institutional care over home care, it supports technology-intensive treatment rather than labor-intensive care, and it fails to provide adequately for chronic diseases.” Page 94
  21. 2. What drives Medicare’s reimbursement policies, especially in regards to hospitalization?
    “Its reimbursement strategies shaved off days at the end of a hospitalization and substituted skilled nursing facility care for those days.” Page 100
  22. 3. What % of people over 65 die in the hospital?
    50% page 102
  23. 4. Gillick states that Medicare undermines the goal of comfort. How?
    “With its powerful incentives to provide nursing homecare rather than home care and curative rather than palliative treatment, Medicare undermines the goal of comfort.” Page 103
  24. 5. Medicare gives nursing homes a financial incentive to switch from labor-intensive, time consuming process of feeding to tube feeding. Explain.
    “If a long-term resident of a nursing home has a feeding tube inserted, she may qualify for transfer to a “skilled nursing facility.” This is often just a different bed in the same nursing home, where her care will be reimbursed at a higher rate simply because she has a new feeding tube.” Page 109
  25. 6. What is the difference between (alternative versions of Medicare) intensive, comprehensive, and palliative approach to care?
    “The majority of robust people will select the intensive plan, most frail people will opt for the comprehensive plan, and the majority of dying patients will select the palliative plan, once they understand whether they are robust, frail, or near the end of life.” Page 117-118
  26. 7. What is the function of PACE?
    “It is holistic, attending to psychosocial and spiritual issues as well as to symptoms and diseases. It does include hospital care but instead seeks to ensure that patients get what they need at home.” Page 114
  27. 8. What would the comprehensive package pay for?
    “The comprehensive package would have to pay for a number of interventions that promote independence, such as hearing aids, glasses and dentures.” Page 114
  28. 9. Gillick encourages Hospice to expand their service to include..?
    “What is now hospice would be expanded to include patients with terminal conditions such as advanced dementia or end-stage heart failure.” Page 115
  29. 10. Currently Medicare determines your health care benefits based on job, age, income, and the state you live in. What does Gillick suggest is a better alternative?
    “It is actually much fairer to determine what health care benefits you receive on the basis of your medical needs rather than your job, age, income, and state..” page 119
  30. 11. Where (location) and how should Medicare assess which of the benefit packages someone should receive?
    “Underlying health status could be assessed in outpatient geriatric assessment clinics or at the time of hospitalization, using criteria that reflect disease severity, functional status, and cognition.” Page 120
  31. 1. What is the chance of someone just turning 65 for spending some time in a nursing home?
    “The latest prediction is that if you are just now turning 65, you have nearly a 50 percent chance of spending some time in a nursing home before you die.” Page 123
  32. 2. How is the “total institution” organized?
    “To put it simply, a total institution is organized to promote efficiency among the staff rather than to meet the specific, individual, and variable needs or wishes of its residents.” Page 128-129
  33. 3.In the nursing home lingo, what is “the accident”?
    “They could come promptly when he asked for help going to the bathroom, saving him from the excruciating embarrassment of what was euphemistically known throughout the nursing home as “an accident.”” Page 130
  34. 4.What bothered Paul the most?
    “What bothered him was his overwhelming feeling of uselessness.” Page 130
  35. 5.What is the predominant goal of a nursing home?
    “But the predominant goal of most nursing homes is the safety of its occupants, whereas the overriding goal of those occupants is typically to enhance their quality of life, even when this entails taking risks with safety.” Page 131
  36. 6. What is the struggle between individual control and nursing home control?
    “They want those things that they regard as essential to maintaining their quality of life—and if quality conflicts with safety, they would opt for quality.” Page 132
  37. 7.What is new Mount? The Pioneer Movement? What is the Green House model?
    “The new Mount, which took ten years to create, is divided into small neighborhoods in which residents “age in place… has made significant progress in nurturing relationships and facilitating meaningful activity.” Page 133 “The Pioneer Movement, at least in principle, values both residents and staff as unique individuals, people who can make a difference in the lives of others.” Page 134 “Known as the Green House model, this plan involves six or eight frail older people living in a house with around-the-clock care.” Page 135
  38. 8. What will Nursing Home Compare tell you?
    “…This website provides four pieces of information: demographics (size and profit or not-for-profit status); performance on a set of “quality measures”; the number of deficiencies identified at the last state inspection; and staffing ratios. Comparisons are presented with state national averages.” Page 137
  39. 9. What were the positive and negative effects of the legislation known as OBRA?
    “Powerful as this legislation has been in cleaning up nursing homes where residents were routinely tied in their seats, sedated to keep them quiet, an left to develop pressure ulcers after sitting motionless in urine-soaked diapers, it has also indelibly stamped nursing homes as institutions devoted to health and safety… Unfortunately, it ensures that nursing home staff will measure and record the activities of residents instead of interacting with them and responding to their needs.” Page 146
  40. 10. What does the Minimum Dates Set do? How is the outcome measured?
    “Every certified nursing home in the country must complete this “Minimum Data Set” (MDS) on each resident annually, with shorter quarterly updates and extensive re-evaluations whenever there is a “change of status,” which is jargon for getting sick.” Page 146
  41. 11. What does Gillick suggest is necessary to revolutionize nursing homes?
    “If we want cultural change to revolutionize nursing homes, we will need a major shift in the focus of government regulation.” Page 149
  42. 12. What did social scientists at the University of Minnesota come up with?
    “Social scientists at the University of Minnesota have recognized how critical it is to be able to define and measure quality of life in the nursing home.” Page 150
  43. 13. Why does Gillick see “now” as the time to get involved (especially for the baby boomers)?
    “But if the boomers wait until we are old and sick, we won’t have the energy to demand change. If on top of being old and sick we are demented, we won’t come close to having the capacity to demand much of anything. The time to act is now.” Page 151
  44. 1. What are the stats on people who live in assisted living?
    “There are 36400 residences in the US that call themselves assisted living, housing just over one million people. The typical resident is an 83-year-old widow, more likely white than black, and more likely paying privately. The average size is 43 units. Residents of assisted living, on average, stay in the facility for close to three years, with a third moving on to a nursing home, 28 percent dying, 12 percent moving in with family members, and 14 percent switching to a different assisted living facility.” Page 160
  45. 2. What was your author’s experience with assisted living arrangements for Saul?
    “Our experience with the world of assisted living was profoundly disappointing. The facility was unequipped to provide the ongoing monitoring and supervision necessary for individuals with cognitive impairment.” Page 162
  46. 4.What was the aftermath of the federal Hill-Burton Act of 1954?
    “Stimulated by the federal Hill-Burton Act of 1954, which granted public money for building nursing homes, new large facilities modeled on hospitals sprang up.” Page 167
  47. 3.What were old ages homes like at the end of the nineteenth century?
    “Old age homes at the end of the nineteenth century tended to be small and intimate… They were culturally homogenous, typically catering to a particular ethnic or religious group… the nineteenth century old age homes were not medically oriented.” Page 165
  48. 5. When does assisted living begin to break down for the patient?
    “Assisted living begins to break down when cognitive impairment is severe enough that person needs frequent reminders so as not to miss meals.” Page 168
  49. 7. How does the median income for people over 65 align with the cost of assisted care? What does state regulation contribute or detract?
    “The median income for people over age 65 in 2003 was $20363 for men and $11845 for women, and the average annual cost of assisted living was $30288 which does not include Medicare premiums or personal items.” Page 178 “The idea that regulations would ensure quality care in assisted living surfaced after a study by the GAO in 1999 turned up evidence of major deficiencies in assisted living.” Page 180
  50. 8. What was the disappointment in the group recommendations from the Consumer Consortium on Assisted Living?
    “The group’s report was a disappointment… Dissenters responded bluntly that “this feel-good language does nothing to inform a consumer” about just what services he can rely on.” Page 181
  51. 9. Is assisted living successful for elders who are cognitively tact?
    Ultimately assisted living is successful for those elders who are cognitively intact, but only if they have money. Page 188
  52. 10. Why won’t most assisted living facilities accept Medicaid? How many of nearly one million people living in assisted living were Medicaid recipients?
    “The level of reimbursement is so low, however, that most assisted living facilities will not accept Medicaid, and those that do generally restrict the percentage of units that they will fill with residents on Medicaid. The net effect was that as of 2003, only 101000 of the nearly one million people living in assisted living were Medicaid recipients.” Page 189
  53. 11. What’s Gillick’s idea of a “new Medicaid benefit”?
    “The benefit would offer long-term care, whether at home, in an assisted living facility, or in a nursing home, to people over age 65 who need help in at least two activities of daily living.” Page 189
  54. 12. What is the “three level” long term care idea and how might it be paid for?
    “Three levels of long-term care, all of which should be paid for by the same mechanisms. The lowest level of care would be very similar to what much of assisted living is today: private apts. With communal dining, on-site activities, and a minimum amount of personal care… The next level of care, suitable for the largest number of people, would encompass the more dependent elders who currently live in assisted living and the less dependent of those who current live in nursing homes… The third level of care would be suitable for the most dependent older people, most of whom currently live in nursing homes, but some of whom are in assisted living facilities for the memory-impaired.” Page 192
  55. 1. What is the ending of Ruth’s story with her new implantable defibrillator?
    “ She died in her sleep, three months to the day after the cardiologist turned off her defibrillator.” Page 203 What relevance does this have to the overall picture? Die when it’s your time. Machines are causing people to live in agony when their bodies are trying to give up.
  56. 2. What does the story of the “Struldbruggs” have to do with aging in America?
    The Struldbruggs are the elderly of America. “Lest there be any doubt that immortality is a curse.” Page 204
  57. 3. What is the compression of morbidity theory? How have rate of disability changed?
    “The debate about whether existing approaches to care will lead to “compression of morbidity” in which the period of disability and dependence shrinks while overall lifespan grows, or instead to increasingly long periods of frailty, is far from settled.” Page 205 “The rate of disability with old age has declined in recent years, giving greater credibility to the compression-of-morbidity proponents, but rates of severe disability remain unchanged.” Page 205
  58. 4. The most theoretical plausible avenue to preventing or delaying aging is?
    “Caloric restriction.” Page 209
  59. 5. By age 90, what % of men and women will have a fractured hip?
    “By age 90, 1/3 of all women and 1/6 of all men will have fractured a hip.” Page 215
  60. 6. What is Bob’s message?
    “Bob’s message, and perhaps that of most centenarians, is that there comes a time to stop.” Page 218
  61. 7. What % of Medicare budget goes towards long term care of the elderly?
    “Moreover, fully a third of the Mediaid budget goes to long-term care for the elderly.” Page 219
  62. 8. What position on aging does the philosopher Leon Kass have on aging?
    “Kass argues that finitude is good for us, in large measure because “to know and to feel that one goes around only once, and that the deadline is not out of sight, is for many people the necessary spur to the pursuit fo something worthwhile…. Mortality makes life matter.” Page 224
  63. 1. What are many elders discovering about what gives meaning to their lives?
    “But many older people are discovering that what gives meaning to their lives is membership in a larger community. Giving to other is proving to be the ultimate source of self-fulfillment.” Page 226
  64. 2. How do frail elders often view their retirement years?
    “Frail elders often view the retirement years as an endless series of medical appointments, punctuated by a rare visit with children and grandchildren.” Page 238
  65. 3. What is unique in the community of Seaside, Florida?
    “A couple of radical architects came up with the idea of the planned community. Their idea was to deliberately design a while town, using architecture to facilitate a sense of community.” Page 244
  66. 4. What is the intergenerational college campus and what does it offer the elders?
    “…Enabling the elderly residents to take college courses alongside the adolescent population… The hope is that the older people will serve as a resource for the students, providing the kind of information about careers that is lacking from the typical career counseling office. They can also act as surrogate grandparents, giving advice and encouragement that teenagers might reject if it came from their own parents.” Page 246
  67. 5. The University of North Carolina vs Lasell College. Compare and contrast.
    “UNC Ashville set up the Center for Creative Retirement… it puts together an extensive program for seniors to promote learning and volunteering. Its “college for seniors” is separate from the regular classes offered to undergraduates.” Page 246 “Lasell College chose to build a continuing-care retirement community on it’s campus… it has fourteen interconnected buildings that house 210 independent older people, has its own skilled nursing facility. Commit and complete 450 hours of educational programs each year.” Page 247
  68. What does Robert Putnam’s work “Bowling Alone” tell us about the generations born after WWII?
    “Robert Putnam, in his seminal work Bowling Alone, identifies autonomy as the sacred cow of the generation born after WWII, in contrast to the civic-mindedness of the “greatest generation”. Page 251
  69. 7.What does Gillick see as the major obstacle in creating communities?
    “The true barrier is our deep-seated faith in individualism.” Page 250
  70. 6.What will the Internet offer the frail elders?
    “With a little ingenuity, an Internet entrepreneur could capitalize on the untapped potential of tens of thousands of older people with services to offer. Advice is the obvious service, but older people could also proofread term papers or provide feedback on college assignments or even facilitate Internet support groups.” Page 249
  71. 9.What radical change is Gillick proposing before we can meet the needs of the elders?
    “Only a radical change in attitude will allow tomorrow’s octogenarians to accept limits on medical treatment, to endorse palliative care at the end of life, and to enjoy their final years in an environment that is truly conducive to fulfillment.” Page 253
  72. 1. What 4 steps does Gillick encourage her fellow boomers to do?
    “What I am suggesting is that we need to change our attitudes, our behavior, and many of our social institutions.” Page 256
  73. 2. What percentage of boomers cast ballots in the 2000 presidential election?
    “In the 2000 presidential election, 59% of the eligible electorate voted, but 69% of older boomers cast ballots.” Page 257
  74. 3. Why does Gillick suggest that people make fewer geographic moves?
    “We never establish roots.” Page 258
  75. 4. Rather than obsessing about Pap smears and PSA tests, what should we be focusing on?
    “We will need to stop obsessing about things that no longer matter, resisting the impulse to request Pap smears and PSA tests, and start paying attention to new areas that do matter.” Page 259
  76. 5. What does “accept the painful need to make trade-offs” mean?
    “We have to accept the painful need to make trade-offs, recognizing that some kinds of potentially life-extending therapy are incompatible with remaining independent, lucid, and comfortable.” Page 259
  77. 6. Why must we give up the single-minded devotion to individual autonomy?
    “Accept the fact that community is tremendously important as we age. If they are to continue to be able to make choices about their lives, they need others to help them implement their decisions.” Page 259
  78. 7. What is the idea of giving elders insurance premium rebates for attending annual seminars on personal health?
    “The medical profession could offer weeklong seminars (conceivably at resorts, featuring a mixture of work and play), or ongoing series of evening lectures, or online educational programs… These courses would not be compulsory, nor would failure to participate be punishable by a fine (analogous to failure to wear a seatbelt in some states), Medicare or senior health maintenance organizations could offer a premium rebate for annual attendance.” Page 260
  79. 8. How are exercise centers and credits for prescription drugs related?
    “An even more potent stimulus would be a system of accumulating points (“Prolific Peddling Points”), analogous to Frequent Filer miles, which could be credited toward the price of prescription drugs or the cost of subscribing to part B of Medicare (coverage for physician service and laboratory tests) or could result in a discount on a MediGap policy.” Page 261
  80. 9. What are the advantages of a single, resident centered model”?
    “This model will seek to promote the highest quality of life for its residents, not just to maximize their physical safety, which is what so much of nursing care is about today.” Page 262
  81. 10. How should we redefine caregiving jobs?”
    We’re going to have to redefine caregiving jobs to make them attractive. That will mean boosting pay, increasing the prestige associated with such jobs, and creating avenues for advancement.” Page 262
  82. 11. How should we move form crisis care to promoting chronic disease management?
    “We will need to enact comprehensive Medicare reform if our health care system is to be reshaped to promote chronic disease management rather than crisis care.” Page 263
  83. 12. Do we need to shift from health and safety regulations in nursing home to quality of life issues?
    Yes. “And we need to focus on quality of life issues: as long as the regulators scrutinize nursing homes for their attention to health and safety rather than to the quality of life of their residents, we will continue to have sterile pseudo-hospitals masquerading as “homes” for the elderly.” Page 263
  84. 13. What’s the survival rate fort hose who sustain a cardiac arrest outside the hospital (after age 70)?
    “Among people over age 70 who sustain a cardiac arrest outside the hospital, fewer than 1 percent survive.” Page 264
  85. 14. What issues are not addressed by commercial television shows that deal with doctors, and hospitals?
    “Among the issues that were never addressed were chronic illness, hospice care, nursing homes, and home care. Even in the realm of end-of-life issues, the programs dealt with refusal of treatment and with do-not-resuscitate orders, but not with quality-of-life concerns, advance directives, or physician-assisted suicide.” Page 265
  86. 15. What percentage of the fictional characters depicted on television or in ads are people over age 65? Women and minorities?
    “Right now, less than 3% of the fictional characters depicted on television, and an even smaller proportion of those featured in ads, are people over age 65. Women and minorities are particularly under-represented.” Page 266
  87. 16.What did George Vaillant find out about the most satisfied old people he interviewed?
    “The most satisfied old people he interviewed cared about and reached out to other people, to whatever extent they could. They accepted their dependency, but maintained hope and believed in doing things for themselves if they could. They retained a sense of humor, took pleasure in their past achievements, and remained curious about the world. Most important, they retained contact and intimacy with old friends, continuously renewing their relationships.” Page 268