Michael Gordon's blog

If one is in medical practice long enough it sometimes seems like that sense one gets when sitting in a waiting room and picking up a years old copy of Time® magazine and not realize that it is years out of date, as many of the stories seem to be the same or very familiar. I have a 30 year old tuxedo which fortunately comes in and out of vogue cyclically which allows me ( as long as appropriate size accommodating alterations have occurred) to keep wearing it without my feeling that I am “out of fashion”.

The challenges that face all practitioners and family members who care for those living with dementia are myriad. Cognitive impairment and behavioural issues top the list of concerns expressed by families, with the second layer being impairment of activities of daily living which requires assistances in many basic domains. Over the years the approaches to care especially for those with the range of behavioural issues which might range from withdrawn apathy to agitated aggression and disruption of other people’s function and privacy. The latter often becomes a problem in congregate living situations and may lead to crises when the facility expresses concerns about the ability to continue care of others’ lives are negatively affected.

In this question for methodologies to decrease these negative or as recently renamed “reactive” behaviours, the typical “medical” approach has generally been pharmacological. This has spawned a whole drug-based industry including regulatory attempts to modify and curtail the use of such medications because of evidence-based negative consequences of the medications which are often additional to the risk of the underlying disease itself. Psychologists, social workers, recreational and music therapists have all added over the years various modalities of interventions with the hope that they might individually or in combination might more safely decrease the degree of behavioural problems without compromising the person’s function, dignity and quality of life.

With this in mind it was refreshing to see recent references to programs in which “doll therapy” was being utilized as a modality to address some of the behavioural manifestations of those living with dementia living in long-term care facilities. The article that brought the program to mind was recently published in the Feb. 3, 2014 web-based article from Nursing Ethics where the focus of the article was on the ethical implications of the intervention more that the efficacy and clinical impact of the use of dolls in BPSD and other manifestations of those living with dementia.

It is of interest that the focus of this particular article was on ethics rather than clinical outcomes. One can of course implicate ethics in all clinical interventions in terms of goals, benefits and risks as well as the foundational principle of ethics; autonomy, beneficence, non-maleficence and justice. When one thinks of alternative pharmacology based interventions for BPSD it is hard to imagine how they would measure against interventions whose adverse reactions or almost exclusively of an “ethical premise” rather than manifestations that can affect the clinical outcomes of the disorder with significant adverse cardiac and other documented potential side effects as well as movement disorders. Other articles on the subject of doll therapy and other alternative non-pharmacological modalities of intervention for BPSD seem to be less focused on the ethics than on the efficacy of the intervention and the multiple benefits to the general emotional well-being of the individual beyond the issue of BPSD.

One of the long-term care facilities to which I provide ethics workshops for the staff that cares exclusively for those living with dementia has had a doll therapy program for many years. At Bloomington Cove LTC facility, the range of doll-based interventions includes individual provision of dolls as well as programs in which groups of residents take part in various forms of care-provision and nurturing activities to the dolls which are of a soft and “cuddly” characteristic. The director of the facility believes strongly that the doll-based intervention brings out the natural and at times vivid desire and latent abilities and wish of almost exclusively female residents to express affection, physical nurturing and emotional attachment that clearly is stored in the repository of their brains and personalities which when tapped release positive feelings and actions which can replace the often disruptive reactive states that BPSD often elicits.

The ethics focus on this intervention which is not new is encapsulated in the Nursing Ethics article which says, “The use of doll therapy for people with dementia has been emerging in recent years. Providing a doll to someone with dementia has been associated with a number of benefits which include a reduction in episodes of distress, an increase in general well-being, improved dietary intake and higher levels of engagement with others. It could be argued that doll therapy fulfils the concepts of beneficence (facilitates the promotion of well-being) and respect for autonomy (the person with dementia can exercise their right to engage with dolls if they wish). However, some may believe that doll therapy is inappropriate when applied to the concepts of dignity (people with dementia are encouraged to interact with dolls) and non-maleficence (potential distress this therapy could cause for family members). The article continues with, “This article suggests that by applying a ‘rights-based approach’, healthcare professionals might be better empowered to resolve any ethical tensions they may have when using doll therapy for people with dementia. In this perspective, the internationally agreed upon principles of the United Nations Convention on the Rights of Persons with Disabilities provide a legal framework that considers the person with dementia as a ‘rights holder’ and places them at the centre of any ethical dilemma. In addition, those with responsibility towards caring for people with dementia have their capacity built to respect, protect and fulfil dementia patient’s rights and needs.”

In contrast to the ethics focus approach to doll-based therapy another article, published by Carefect, focuses primarily on the beneficence (benefits) impact of such intervention as follows, “Doll therapy provides many benefits for Alzheimer’s patients that engage in it. One of the most important benefits of doll therapy is that it provides Alzheimer’s patients with social interaction and allows them to have the chance to care for someone again instead of just being the person that is being taken care of. Many seniors are calmed by their doll and it can often create a distraction for them from upsetting events. Having a baby doll often reminds Alzheimer’s patients of fond memories of when they were a new parent which can have a very positive effect on them. Many seniors will enjoy rocking their baby doll which can also help them fall asleep if they have trouble sleeping themselves. Family caregivers looking for activities for their loved one can try purchasing baby doll clothes or even actual baby clothes for their loved one to put on the doll. Many of the lifelike dolls are big enough to fit in newborn clothing, so family caregivers can purchase a few outfits for their loved ones to put on their doll. Family caregivers can even consider buying a stroller for the doll so that their loved one can push it around the house and get some exercise while playing with their doll. Many seniors enjoy singing to their doll, so family caregivers can join in or encourage their loved ones to sing on a regular basis. The most important thing though is to make sure that all family members are educated on doll therapy. Many people may find it odd to see their elderly loved one playing with a doll, especially if they were not educated on the way doll therapy works and the benefits of such therapy for people suffering from Alzheimer’s or dementia.”

What does this mean for those responsible for providing as much as possible sensitive, client-focused, beneficent and the least harmful interventions possible that will allow those living with dementia to experience the least conflict and anguish in their emotional experiences? This should be while promoting as much as possible some semblance of quality of life and emotional connectivity with their world, however distorted or limited as it might be because of their cognitively impaired state. Although as in all aspects of medical and other health care interventions the ethical implications cannot and should not be ignored, we in the healthcare professions must be careful to make sure that our approach is sufficiently balanced with the focus always on the well-being or those we care for and the realization that in a complex world of caring for those with dementia, there may always be some question remaining in the realm of ethics, but these must not supersede the real daily beneficial impact that may accrue to those we collectively care for. Doll Therapy as well as the wide array of alternative therapeutic interventions should be high on our list of considerations as we struggle to make the life of those we care for whose scope of enjoyment and social participation may be limited by their disordered brain functioning.

This blog was originally published at: http://www.annalsoflongtermcare.com.

When I tell people that what I do professionally is “look after older people,” I often hear responses such as: “Oh, that must be so depressing;” or sometimes, “Isn’t that wonderful, you must be a special human being;” and on occasion, “there are so few of you—what will be in the future with so many old people using up health care resources?” When I add that I am also involved in palliative care, you can imagine the response, but usually permutations on the “dealing with death every day must be the most depressing thing a doctor can do, how do you do it?” Just think, combining looking after the elderly person in a palliative care setting might be interpreted by those who have never had to experience such a combination as the ultimate in depressing; something that only a “saint” or “medical masochist” would choose as a profession.

First, to settle the issue, my colleagues and I involved in the same domains of medicine are neither saints nor, for sure, masochists. In fact, I could say that for all the health care providers, such as nurses, occupational and physical therapists, social workers, dieticians, and pharmacists, undertake their professional responsibilities with dedication, commitment, and the utmost in humanity. They usually combine these attributes with an enormous respect and interest in the narratives, the family interactions, and ties that each of their patients bring with them, irrespective of their illness. Having spent a career undertaking many aspects of medical practice from Internal Medicine and all of its subspecialties, including intensive care, I have no hesitation saying that my colleagues and I probably share much good humor, laughs, life’s pleasures, and experiences, as well as tragedies with our patients and families. They all share a wealth of human experience with all its fascinations, accomplishments and disappointments.

Within this context it is worth considering the wide range of beliefs and values that older people and their families carry within them as they contemplate the latter period of their life. This may be combined with significant personal physical pain and psychological anguish. At times there is the clear acknowledgement that they are “getting close to the end” and do not want to prolong a life that they have long ago accepted as finite and do not wish to risk suffering during their very twilight days, weeks or months.

It was with this in mind that I was especially impressed by a few newsworthy items that seemed to address the universal human struggle about life and the trajectory towards death from different perspectives. First there was a very moving piece in the February 2, 2013, New York Times written by Louise Aronson, an associate professor of medicine and geriatric specialist at the University of California, entitled, “Weighing the End of Life,” which in fact focused on her aging dog and all the trials and tribulations she faced deciding on when “enough was enough.” She eventually decided to have this wonderful, loving, and loved pet put down. In the article she mused, “Since then (after the dog was euthanized), I have often wondered whether we waited too long. We counted the time he spent sleeping as contentment ... I know that in elderly humans, sleep is more often a sign of chronic exhaustion, depression, and avoidance of pain. In dealing with the guilt brought on by our mixed feelings — we love him; he’s ruining our lives — I realize we may have overcompensated to his detriment. With dying humans, similar situations arise every day: hospital stays that fix the acute problem and worsen the chronic ones; emergency department visits that yield diagnoses, but require weeks of recovery from the waiting and testing; surgeries that are themselves minor, but provoke major confusion, complications, and hated nursing home stays.” She finished her essay with the story of a very elderly man with many illnesses who refused hospitalizations recommended by her. As she says in her final sentence, “He wanted to live — just not in the hospital, with poisons in his blood. He was sick and tired of feeling sick and tired. Like so many, his was a reasoned and reasonable stance.”

Reading her essay reminded me of one of the latter poems of Dylan Thomas (1914-1953) published in 1951: “Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light. Though wise men at their end know dark is right; Because their words had forked no lightning they Do not go gentle into that good night”. In the poem, the message is about fighting against the end of life while acknowledging the difficulty entailed and the struggles associated with the coming of life’s termination.

Of interest was at the time of The New York Times article about the dying of a dog, Pope Benedict XV1 shocked the world by his decision to step down as Pope, the first time in 600 years that such an event has occurred. The move raised a wide range of questions and speculation about the reasons and whether it would have been better to stay until his death, “fighting against his age-related (he is eighty-five years old) physical and emotional decline. As reported in a Time Magazine article on his decision, he wrote in his letter of resignation, 'After having repeatedly examined my conscience before God, I have come to the certainty that my strengths, due to an advanced age, are no longer suited to an adequate exercise of the Petrine (Papal) ministry ... this ministry, due to its essential spiritual nature, must be carried out not only with words and deeds, but no less with prayer and suffering. However, in today’s world ... both strength of mind and body are necessary, strength which in the last few months has deteriorated in me to the extent that I have had to recognize my incapacity to adequately fulfill the ministry entrusted to me.'”

There is a contrast to the final years and months of the previous Pope Jean Paul 11, who prior to his death, according to a report in the American Catholic website, spoke with increasing frequency about his age, his failing health, and death. The Vatican never formally acknowledged that the Pope suffered from Parkinson’s disease until after his death, although the tremor in the Pope's hand became unmistakable in the early 1990s, and media references to Parkinson's disease circulated for a decade before the Pope's death. In 1996, papal spokesman Joaquin Navarro-Valls was given a formal reprimand by the Secretariat of State for making a public comment about the possibility that the Pope was suffering from an "extrapyramidal syndrome"— an indirect reference to Parkinson's disease. Unlike Benedict XVI, he was determined to stay at the helm of the church, but also said he was prepared to be called to the next life. "It is wonderful to be able to give oneself to the very end for the sake of the kingdom of God. At the same time, I find great peace in thinking of the time when the Lord will call me: from life to life," he said in a 1999 letter written to the world's elderly. One could argue if staying at the Church’s helm in a state of failing health does more of a service to the Church than to resign as Benedict has done.

The last relevant media story reflecting when “enough is enough” is the suicide note, reported in a Globe and Mail newspaper letter to the editor published on Feb 8, 2013. In it, Ruth Goodman of Vancouver, writes, “I am a 91-year-old woman who has decided to end my life in the very near future. I do not have a terminal illness; I am simply old, tired and becoming dependent, after a wonderful life of independence. People are allowed to choose the right time to terminate their animals’ lives and to be with them and provide assistance and comfort, right to the end. Surely, the least we can do is allow people the same right to choose how and when to end their lives … I am writing this letter to advocate for a change in the law so that all will be able to make this choice.”

Of interest in terms of the wording chosen to describe the Pope’s decision to resign, Cardinal Timothy M. Dolan, the archbishop of New York, said, “By stepping down, the pontiff was saying, ‘my death is here; I feel weak, I feel fragile, I am frail.’” These words seem to echo those of Ruth Goodman. One can almost project that for a Pope to resign, something that has not been done for centuries, that might be in many ways akin to voluntarily leaving this world or at least what in essence is his world.

There were many letters to the editor following the printing of Ruth’s letter, some missing the point and referring to the “value” of the elderly rather than the issue which was Ruth’s concern, the personal decision to determine in one’s own world and life and when for each individual, “enough is enough”.

Acknowledgement
This article was first published on www.bestthinking.com

References
1. Aronson L. Weighing the End of Life. New York Times, February 2, 2013. http://www.nytimes.com/2013/02/03/opinion/sunday/weighing-the-end-of-life.html?_r=0&pagewanted=print

2. Thomas D. Do not go gentle into that good night. Poetry.org. http://www.poets.org/viewmedia.php/prmMID/15377

3. Text of Pope’s Resignation Announcement. Time Magazine: Associated Press Feb. 11, 2013. http://world.time.com/2013/02/11/text-of-popes-resignation-announcement/

4. Goodman R. Her last choice. Globe and Mail, Feb 8, 2013. http://www.theglobeandmail.com/commentary/letters/feb-8-lawyer-love-and-other-letters-to-the-editor/article8367639/

I have for many years enjoyed my family name, Gordon, and all the connections I can make with it. I learned when I was quite young, from my paternal grandfather that the name had been ours for many generations and had not been changed as had those of my childhood friends. I had stored that knowledge deep into the recesses of my memory. When I decide to study medicine in Scotland, the name became a talking point, as everyone assumed that with that name I must in fact have Scottish ancestry. I could only explain that the name was genuine, unsullied by arbitrary or deliberate alteration by American immigration authorities when my grandfather arrived from a small village in Lithuania.

It was only some years later, during my first trip to Israel that I read a history of Russia by a Scottish historian. There I found a reference to the likely origin of the Jewish Lithuanian and by dint of migration Russian Gordons. It was Peter the Great's desire for territorial expansion that led him to hire a militarily brilliant Scottish mercenary general by the name of Patrick Gordon. It was General Gordon, who successful in many Russian expansionist battles ultimately became a close friend and confidant of the Tsar. A well detailed biography of Peter the Great by Robert Massie explains how Gordon's death was mourned by the Tsar as a loss to his empire. During the later emancipation process, when Russians adopted family names, it appears that my ancestors, in deference and regard to the Tsar's great friend took on the name Gordon. Although there are varying iterations on the origins of that name in Jewish Russian/Lithuanian history, this narrative has always seemed to me to be the most credible.

During the pogrom-dominated anti-Jewish period in Russia around the turn of the 20th century many Jews left Russia, including my ancestral village of Eysheshuk I near Vilna and made their way to the United States, then British Palestine and South Africa. When I was sitting my oral examination in Midwifery in Dundee Scotland, then still part of the University of St. Andrews, my examiner was the "prof" (professor and head of the department) himself. As I sat down he said, "You're the Yank" in his mellifluous Scottish dialect which by this time had become music to my Brooklyn English ears. "Surely" he continued, "with a name like Gordon, you must be Scottish." I responded with a "yes and no, but if you would like to hear the story, I would be happy to tell you." He nodded yes and with my eye on the clock above his head, ticking out the 10 minutes of oral examination time, I recounted the tale. With 30 seconds left, he interrupted with "Oh dear, Oh dear, we're running out of time, followed by 'give me three symptoms or signs of eclampsia'". I knew the answer "cold" as it was one we all prepared for knowing how important the subject was. As I turned to leave the room I saw him write a 10 and say, "very good, very good" in broad Scottish.

That event resulted in a prize in midwifery much to the shock and surprise of my classmates as it was not my "strong" subject. With the 500 pounds I spent 5 months doing midwifery and gynaecology at the Rambam Hospital in Haifa, which resulted in epiphany in my life which circuitously resulted in Aliyah some years later. My return to North America and settlement in Canada is complex but I have always responded to the name Gordon with the question to determine if the person was perhaps a landsman and if they are aware of the history of the name. This has resulted in many warm interactions and sharing of family histories.

This was personified on a recent invitation to Vancouver to attend a conference as a presenter. After the acceptance I received a request to attend a meeting of the newly established Vancouver chapter of the Israel Medical Association, having been involved in the Toronto chapter for many years. Once accepted I received an email form Dr. Paula Gordon, a Vancouver radiologist who trained at Mt. Sinai Hospital early on in my career as a clinical teacher.

At the IMA meeting, Dr. Marla Gordon, an elder-care focused primary care physician at whose house we were meeting introduced herself and reminded me that years earlier she had asked me via-email about my knowledge of the derivation of our name. Also at the meeting was Dr. Rhona Gordon, a family physician with a major focus in Obstetrics and newborn care, is married to the president of the Vancouver IMA. We spent much of the post-meeting time comparing our family histories and our understandings of the movements through Europe and North America of our respective Gordon families. We concluded the we were for sure Landsman (a Yiddish term for people of the same geographic area—which in 18th and 19th century Eastern Europe usually meant the same village or district. I could add these three to other Gordons living in Israel who also I knew as émigrés from Eyshoshuk or other parts of Lithuania.
This experience reminded me of the importance of keeping people with cognitive impairment as grounded as possible with ideas, events, people and associations that they can relate to and which are meaningful. The use of photographs is very important in helping those living with dementia relate to important people and events in their life. The nice thing about the use of photographs is that they can be shown and discussed time after time without the person getting bored as they may have little recollection of having looked at the pictures recently. (/article/photography-many-windows-memories). It has been shown that familiar and personal music is also useful to those living with dementia and the fact that the person can related to their music has been demonstrated to bring back important memories that may result in revitalization of the person even within the context of dementia and may also be useful when dealing with behavioural issues such as agitation (http://www.youtube.com/watch?v=Fw7Y78aqf_I).

What could be defined and an expansion of one's historical connections also resulted in a recognition of the importance of individual roots and relationships. As physicians dealing with dementia we should also try and explore and find those aspects of our patient's lives and experiences with which they can connect, and if we can add to or enhance that connection, all the better for a fulfilling and meaningful and ultimately more successful clinical experience—for the patient and for the physician.

When one thinks of music and movement, the natural association is dance. In all parts of the world and in all cultures, there is some musical expression through dance, ranging from what may appear to be relatively simple rhythmic movements to compelling drum beats to complex ballets with narratives and dozens if not more dancers doing intricate steps to full blown orchestras. Anyone that has raised children recalls how even very young children, will move and shake to rhythmic music and the massive industry in all western countries of dance lessons starting with child students attests to its natural attraction and ability to fulfill what appears to be an intrinsic human desire.

I recall as a child being taken to ballet, modern dance, musicals with dance and even the renowned Rockets at the Radio City Music Hall by my mother who herself had been a serious amateur dancer in her youth and then a lifelong ball-room and late-life folk dancer with her seniors' centre on West End Avenue in Brooklyn. There was even a period of my pre-teen years when my mother attempted to teach me ballet steps at home which very soon was transposed into my desire to learn to dance to Rock and Roll, using my sister four years my junior as my every accommodating dance partner. Even many years after, in our mature and pre-senior years, at family celebrations we often could still do a dance number to something of the order of Rock Around the Clock or the theme song for Saturday Night Fever. She has continued to engage with multi- cultural folk dancing whereas I have slowed down considerably in my abilities to participate although I enjoy watching others, dance especially my children and more recently my granddaughters.

The general assumption probably held by most individuals that with physical and especially neurological disability, the ability to engage or think about participating in dance would likely naturally diminish. For people living with conditions that impose physical challenges to free and fluid movements, the idea of dancing is more often a dream than a reality. It is likely that it would not even enter the consciousness of most people with neurological disorders, especially those like Parkinson's Disease might be able to participate in, respond to and benefit from music, especially when it is within a framework of dance.

With this in mind the recent article in October 25th issue of The Globe and Mail, by Gayle MacDonald, "Unlocking the secret of Dance" was exhilarating and inspiring. In a partnership with the world-renowned Canada's National Ballet School, with the collaboration and influence of some its most prominent members and in a cooperative effort with among others Toronto's York University and my own Baycrest Geriatric Health Care System, it is hoped that in addition to the great joy satisfaction that all the participants appear to be getting from the program, scientific research studies will demonstrate the mechanism of responsiveness and hopefully clinical improvement.

Dance appears to provide a number of benefits to those living with Parkinson's disease which affects seven million people world-wide including approximately 100,000 in Canada and a million people in the United States. It has been established that dance improves characteristics like balance, gait, posture and other physical measurements beyond the social joy and satisfaction from what is in essence a group and social undertaking. Studies are underway to try and determine what the dance does to the brain and the mechanisms by which improvements may occur and whether or not they are sustainable and may be an important adjunct to commonly used medication therapies that are not without their problems.

It has been well known for many years that those living with Parkinsonism can improve their gait by listening to rhythmic marching-type music and some have learned to use ear-phone-directed march music from iPods and other similar devices to provide the compelling rhythmic background to assist in their walking. (Neuroscience and Biobehavioral Reviews: Into the groove; Can rhythm influence Parkinson's disease? Cristina Nombela, Laura E. Hughes, Adrian M. Owen, Jessica A. Grahn, 2013. http://www.ncbi.nlm.nih.gov) In my own practice I have often taken my patients with such movement disorders and while walking with them up the corridor outside my office I hum loudly a well-known John Philip Sousa March, The Stars and Stripes Forever which most people recognize. Quite a lot of the patients and the family are amazed how all of a sudden the person who had been struggling with gait and speed would be walking alongside me to the loudly hummed musical refrain. If the result is good I instruct the person or family member to get some recordings of such marches or others if they are ones that resonate and put them on an iPod type device and place the march when the person wants to go for an enjoyable walk, for the purposes of actual exercise, or as one might in a garden or along a neighbourhood street.

If this Parkinson's ballet dance project proves successful it may result in a wide range of programs that bring dance and music to many individuals living with Parkinson's disease and provide a creative and satisfying and in many ways liberating enterprise for them.

In North America, although Canada and the United States are separate countries, and each State and Province have their own areas of jurisdictional responsibility, both countries share the legal formulation that Supreme Court rulings set precedential interpretations of the law. Jurists, lawyers and legislators on both sides of the border often draw freely from each other's jurisprudence. Thus, the recent Rasouli decision by the Canadian Supreme Court should make physicians and policy makers on both sides of the border look carefully at the ruling's implications.¹ It would then be prudent for those given the mandate to protect at the same time the integrity of responsible, ethical and professionally sound health care to avoid the potentially negative impact this current ruling can have on patients at the end of life and those whose professional duty is to assure the most humane care possible.

As gracefully and forcefully explained and commented on by one of Canada's foremost ethicists, Arthur Schafer, the potential implications for the future of health care are profound. To quote, "The Supreme Court of Canada's 5-2 decision in Rasouli is a clear victory for the family. Sadly, it is a loss for common sense and common humanity. It is also a blow against physician integrity and potentially damaging to the Canadian health-care system."² As Schafer explains in his article, "The salient facts in this case are these: Hassan Rasouli has been unconscious and on life support since October, 2010. He is in a near-vegetative state with no realistic prospect for recovery. Although his body will inevitably deteriorate further, he can be kept alive, almost indefinitely, in a hospital intensive-care unit: He needs a tube down his throat so that he can breathe, a catheter in his bladder, large central tubes for fluids and medications, frequent surgical removal of infected skin tissue to prevent gangrenous infections, suctioning of his lungs to remove fluids that would choke him".

As Schaffer notes, "Mr. Rasouli's physicians propose that he should be given palliative care instead of life support. Continued ICU treatment is not merely "futile"; it is actively harmful. It can keep him alive, of course, but life is not an absolute value. Physician ethics does not permit procedures which on balance are harmful to the patient. Mr. Rasouli's wife, Parichehr Salasel, insists that her husband, as a devout Muslim, would want to be kept alive, even in these circumstances. She is his substitute decision maker (SDM or in American parlance Proxy for Health Care Decisions) and she refuses to consent to his discharge from the ICU and transfer to a palliative care program.

The judicial nuances and arguments in this case are not as important as the ultimate decision which was that according to the Supreme Court life support can be discontinued only with the consent of the patient or the SDM (proxy). Of equal interest of "rights" of patient autonomy is the hard fact that according to Schaffer, "in Canada, care in an ICU costs almost $1-million a year, per patient. Understandably, the number of ICU beds is limited and admission is strictly controlled." The numbers in the United States would be higher as almost all health care costs in the United States are substantially higher than their comparable cost in Canada.

The salient argument of Schaffer and one which appears already to resonate through the medical community as well as the administrators of hospitals is that, "The purpose of critical care is to save the life of the patient until the patient can recover to be discharged. The ICU is not intended for patients who can never recover. At present, critical-care doctors err on the side of admission. If they later discover that continued life support is futile, then the patient is discharged and receives palliative care instead."

If that equation is no longer assured, it could be that there will be a reluctance on the part of ICU physicians to admit patients who have small or marginal chances of ICU benefit if the risks are that treatment will have to be maintained long past the ability of the health care system to provide a degree of meaningful return to function—the use of religious standards could potentially endanger the integrity of the health care system; what limits can one then put on any religious belief that demands continued medical treatment no matter what the anticipated clinical outcome—modern medicine can keep organs going for a very long time.

As Schafer points out and something that is not addressed adequately by this current ruling but which is one of the foundational ethical principles on which modern medical practice is built is distributive justice. As he notes, "One person's provision is another person's deprivation." It is not hard to imagine a situation where a clinical situation was like Rasouli when the decision was made to admit him to the ICU. What if he had to been deprived of that admission and chance of recovery because another patient like Rasouli is now and whose family demanded continued treatment despite what many would deem to be futile or at least clinically non-beneficial treatment. One can imagine the implications of a patient dying because of ICU deprivation because of someone whose use of the ICU is outside it designated mandate.

Schafer's final conclusion is, "Cases such as those involving Mr. Rasouli…are comparatively rare. With sympathetic discussion and dialogue, a consensus can usually be reached. But in those cases where agreement is impossible to achieve, physicians are entitled to exercise their professional judgment. If the family disagrees, they can appeal to the courts." That is what happened in this case and the result is now part of the new equation of health care decision making.

The potential consequences remind me of a conversation I had some years ago with an American obstetrician and gynaecologist who said he had given up obstetrics because of the number of legal negligence cases he was handling at any given time. As he indicated, "Not having a perfect baby is always followed by a negligence or malpractice charge and even if at the end I am vindicated, the stress on my life in addition to my enormous malpractice insurance premiums are just much for me. I will just do gynaecology" Even for those who believe that births should be "natural" and promote the greater use of midwives, when things go wrong, it is physicians who provide the salvage. If they no longer will take on that role….it is the public, the potential mother and child who will be the victims.

For those of us who do eldercare and long-term care, what we can do is try to promote advance care planning in a way that assures that people address their future wishes and values and make sure SDMs and proxies will carry out their wishes and they really do understand the implications of their decisions. If one cannot be sure a proxy will indeed carry out the instructions it might be necessary to appoint an impartial person rather than a family member so that the emotional impact of what are often heart-wrenching decisions can be made according to ones' expressed wishes and values.

References

1. Handelman M. Consent to Life Support: What the Supreme Court Said in Cuthbertson and Rubenfeld v.Rasouli
2. Schafer A. Right-to-die ruling: Win for families, loss for common decency. The Globe and Mail, Oct. 18 2013
3. Youn A. Health care act's glaring omission: liability reform. CNN, October 5, 2012

It is clear to anyone who has lived with and cared for someone experiencing dementia or looking after a group of such individuals in a long-term care facility, that the issues of memory and recall are not the ones that play havoc with the individual and their caregivers, but the behavioural challenges. Not everyone with an illness causing dementia develops behavioural issues, often called BPSD (Behavioural and Psychiatric Symptoms of Dementia) but for those in whom this occurs, it might have a critical impact on the life they lead, the care they receive and the potential exposure to treatments that potentially might negatively impact their function, quality of life, place of residence or according to some studies life expectancy.

Studies done in the United States over the past decades and in parallel in Canada have been critical of the apparent ease and frequency with which residents of long term care experiencing BPSD are exposed to classes of medications called neuroleptics, which more recently have been subdivided in the older typical and the newer atypical neuroleptics or antipsychotics. It is always important to remember that these classes of medications were initially developed to address psychotic experiences and behaviours of those experiencing schizoaffective disorders in which delusions and hallucinations may be paralyzing to the individual and their introduction into care during the past decades, in series with the typicals preceding the atypicals; it has allowed the virtual emptying of the previous chronic psychiatric hospitals and has allowed many individuals living with such illnesses to manage in community dwellings with many normal aspects of life including educational and work experiences and abilities. In parallel, for many previously fractured families who have been able to re-incorporate family members with unmanageable and disruptive psychotic symptoms back into a family structure.

Almost as an after-thought, the use of these medications in older individuals who were experiencing symptoms similar to those of younger people with clear mental health, schizophrenic-type syndromes. These individuals were found to benefit from these medications in terms of the BPSD which often had some of the similar characteristics, at least on the surface of delusions and hallucinations which often affected their ability to live in community settings at sometimes forced those in some congregate community dwellings to be discharged because of what was interpreted as disruptive behaviour. With the apparent increased exposure to such medications, many of the products obtained negative reputations as did the long-term care facilities that seemed to use them excessively. With some initial studies it appeared that first the atypical medications appeared to be associated with excessive mortality profiles, mostly due to cardiologic disorders and then on closer scrutiny the typicals appeared to have the same negative side-effect profile. (http://www.nejm.org/doi/full/10.1056/NEJMoa052827)

This has resulted in policies in both the United States (Federal Nursing Home Reform Act (OBRA'87) Law & Legal Definition- http://content.healthaffairs.org/content/20/6/128.full) and in Canada to decrease the use of such medications in long-term care facilities, with either very complex administrative procedures to be able to use the medications in the first place and fairly substantial bureaucratic steps to continue their use. There are mechanisms in Canada whereby the volume of such medications used are scrutinized and the governmental administrative bodies that monitor such use may criticize or even penalize the organization where excessive use is deemed to be occurring.

It was therefore quite an eye-opener to read the article, "The Long-term Effects of Conventional and Atypical Antipsychotics in Patients with Probable Alzheimer's disease" published in American Journal of Psychiatry September 2013 (http://www.ncbi.nlm.nih.gov/pubmed/23896958). In the article the authors followed a cohort of 957 patients with dementia to time of nursing home admission or to death. Of the cohort about 25% were provided with either a typical or atypical antipsychotic. After adjusting for all the variables, it was concluded that it was not the medications that was responsible of increased nursing home admission or apparent increase incidence of death, but rather the underlying degree of psychosis and agitation experienced by these patients. If this is the case, it might result in a change in the way we address individuals with these symptoms.

No one, based on this study would re-introduce antipsychotics in an excessive cavalier fashion, but on the other hand the excessive fear held by physicians and families might be quelled somewhat with a proper balance of indications, dosing and the attempts at withdrawal after defined periods so that those who might truly benefit from these medications will receive them as required rather than using alternatives which may have their own inherent dangers and contra-indications. There are studies that demonstrate some potential benefit for some residents of long-term care for whom withdrawal is possible. (http://www.ncbi.nlm.nih.gov/pubmed/23543555).

There are pros and cons of the new digital world. On the one hand for physicians the transmission of important medical information, especially about advances in medicine and concerns about well-established or novel treatments assists all of us in the world of health care to be as “up-to-date” as possible. Anyone in the field recognizes that there is an apparent constant Rocky Mountain avalanche or Hurricane Sandy flood of new information coming from endless sources ranging from the most respected- evidenced-based medical journals to free-wheeling, shoot-from-the-hip internet news sites that churn out information so quickly that there is often little time to attempt to verify the sources of the information and when it catches on the distribution is faster than a speeding bullet through the so-called “going-viral” process.

In reality, true, meaningful and reliable progress in medicine is usually slow and incremental; eventually there is what seems at times to be the slow tortoise-paced movement in positive and meaningful directions. Physicians and consumers of health care information (doctors call them “patients”) are routinely subjected to claims of “breakthroughs”, “major steps forward” and “almost miraculous” advances for one confounding medical condition or another. It is often claimed thatsomeone, which may mean the corporate pharmaceutical industry, the conservative “self-serving” medical profession and politicians who are “in the pay of” one of these mega-wealthy interest groups, that are repressing these breakthrough advances because of a threat to their financial interests or their “monopoly” on the health care industry. The current penchant for conspiracy theories promotes the suspicion held by many members of the public that if there is something missing in their health care, it is due to lack of useful information being purposely withheld or squelched by "vested interests."

When it comes to the categories of serious and often life altering or life-threatening illnesses, there is often an attraction to those for whom either intentionally or unintentionally misleading the public can be a major issue and for some can lead to devastating results. As a physician whose professional and academic interests have covered Alzheimer’s disease and other causes of dementia, end-of-life and palliative care and medical ethics, it is not hard to come across an array of individuals and situations in which it is hard to not consider the concept of mythology if not more accurately charlatanism. With all of such situations it is often the marketing of the product or procedure that becomes the goal of those for whom the potential for vast financial gain becomes a major issue—this can ultimately lead to at best misjudgement or excessive good intentions or naivety and at worst actual fraud.

A few examples to illustrate the history of mythology and marketing in medicine with a focus on aging and dementia and "incurable" illnesses is worth considering. Recently the son of one of my patients whose is living with fairly advanced dementia of the mixed-Alzheimer’s-vascular type wanted to know about my opinion of the use of coconut in its treatment. I admitted that I had not heard of that but he had his internet print out in his hand and right then and there  we logged on to the report including the YouTube depiction of the wife of the patient whose clinical condition of dementia was vastly improved by the eating of grated coconut and then the “medical”: commentaries that followed.  I could understand why a family member of someone with as serious condition as dementia would be mesmerized and hopeful that such a discovery would be beneficial for his suffering mother.  I did a further in depth review of the available literature which mainly referred back to the initial YouTube presentation. All the credible commentators agreed that although interesting there were no proper evidence-based studies that had been done to verify this one in essence case-report. A robust review of the claim and the medical supporting evidence can be found on the website snopes.

Another very popular “natural” purportedly natural preventative treatment for dementia that has been very popular for many years is Ginkgo Biloba, on which according to a 2009 Consumer Reports (CR) wrote that Americans spent in 2007 about $107 million according to the Nutrition Business Journal. They're probably hoping to enhance memory and increase mental focus, claims often made for Ginkgo.

According to the article in CR; “the results of a major trial published in a 2008 issue of the Journal of the American Medical Association suggest that taking Ginkgo Biloba to prevent cognitive impairment or dementia is probably a waste of money. Researchers followed more than 3,000 people age 75 or older for roughly six years—the largest Ginkgo-dementia trial ever. “The supplement did not decrease incidents of Alzheimer's disease or other dementias in people with normal cognition or in those with mild cognitive impairment. Bottom line : Ginkgo Biloba supplements can cost about $200 a year. Save your money. An accompanying editorial stated: "users of this extract should not expect it to be helpful. And while the supplement is widely considered to be safe, there is some concern about an increased risk of bruising, bleeding, and potential drug interactions . If you intend to take the supplement, discuss it with your doctor first.” The same negative results were reported in a more recent article : Ginkgo Biloba no better than placebo in preventing dementia published in the December 2012 edition ofMenopause International.

One only has to wander around any pharmacy’s health supplements section or shopping mall’s health and nutrition outlet or to one of the “big box” stores like COSTCO® and you will see bottle after bottle of nutritional brain enhancing supplement being bought by the truckload. As physicians I think we have a duty to inform our patients that there is no evidence for any benefit of these products rather than take a very common posture which is, “if it can’t hurt, what’s the difference?”

Money saved on useless and heavily marketed supplements can be used for more beneficial purposes, even if to support a worthy charitable cause.

This article was originally published online at www.clinicalgeriatrics.com.

The Clinical Scenario
It was one of those unusual clinics where I saw three similar cases in which the exact same issue surfaced and I was able to demonstrate in “real time” to residents in training with me in the care of the elderly. The first of the encounters was with a couple accompanied by two family members; the couple lived at home with some personal care help and each had some degree of cognitive impairment but not enough to completely interfere with reasonably safe functioning when under some supervision. I was interviewing and examining one member of the couple and my resident was doing the same to the other.

Denial or Hearing Impairment: A common scenario
As I embarked on my interview with the patient it became clear that as noted in previous visits, he was quite hard of hearing. According to the son who was with him, his father refused to wear his hearing aids because “they bothered him” and he often stated that he had, “no problem with hearing”. Each time I spoke to him, he leaned into me to hear my question or answer and turning to the son to repeat the question.  With his wife the resident also noted in addition to some degree of cognitive impairment a significant degree of hearing impairment.

Low cost, effective hearing enhancement: very dramatic at times
I retrieved my Pocket Talker® which I keep in the office for such cases. I put the simple earphones first on him and gradually turned the volume and suddenly his face lit up as I asked if he could hear me and he said, “very well”. We practiced a bit with the device until it was clear that he could engage in a three way conversation with his son and me.  The resident was now ready to review the wife’s issues with me and the son entered the room with us as did his father. They had already learned from me that during the discussion, while I asked questions they were to sit quietly despite a desire to “help with answers” unless I asked them specifically to comment on something said to me by the patient. The resident had reiterated the story to me of mild dementia he mentioned and emphasized that she was quite hard of hearing; she had refused hearing aids although the family was planning on acquiring them. I retrieved the Pocket Talker® that I had just used with her husband, put on the head phones and as I increased the volume, like her husband her face lit up when she heard my questions and I looked at the son and husband and said to them, “maybe you can get a deal if you get two of these”.

A hearing augmentation “Hat trick”
Later in the clinic, a different resident saw another patient. This resident had not been apprised of the experience that I and my other resident had with the couple. She recounted a history of progressive cognitive decline and also mentioned an issue with hearing that the accompanying daughter raised. Like the previous couple the daughter said her mother absolutely refused to go for a hearing assessment and said that she did not want “hearing aids” as she “did not need them” and they were in any event “a waste of money”.  I carried out the same manoeuvre that I had used with the previous couple. Although less dramatic than the previous cases, the way she responded to my repeated questions clearly indicated that she could hear better with the device.  In this particular case,  I was not convinced yet that some of the apparent cognitive impairment may have been perceived as such due to her hearing impairment or at least aggravated by it.  I explained to the daughter when I said I was not yet sure of the degree of cognitive impairment, “if you can’t hear it, you can’t remember it”.

Don’t overlook Hearing as part of the Cognitive Assessment
In these three situations during one clinic session the young residents who in their careers would see many elderly people with cognitive impairment or dementia, the message of the importance in hearing was clearly demonstrated.  It can be hard to convince older people to utilize hearing aids or pay for them. For many a simple and inexpensive Pocket Talker® may be a device that can be used  as an introduction to the benefits of hearing enhancement or may on its own solve the hearing deficiency problem for the purpose of social communication.

                 

Most health care professionals involved in eldercare have had the experience that some of those we look after seem to be able to recall past experiences with a degree of intensity that may be very disquieting and may even lead to what gets interpreted as agitated behaviour. These same individuals may have had the personal experience as I have from my own life experience, some memories; even those very distant, when recalled are almost as vivid as when they first occurred. Depending on the nature of the recalled experience, the impact can be calming, soothing and satisfying or very disturbing. On a personal level, when I wrote some of my life stories, which ultimately became my memoir, Brooklyn Beginnings: A Geriatrician's Odyssey, many of the experiences I recounted were so vivid that I could almost hear the voices, smell the smells and taste the flavours that accompanied the experience.

In my primarily ambulatory geriatric medical practice, which focuses heavily on patients with some degree of cognitive impairment and dementia, memories that do get recounted from the distant past sometimes appear to the person to be almost occurring in the present. Family members often remark that the person cannot recall what they had for breakfast but recall in vivid detail the Atlantic crossing from Europe in 1905. My grandmother who helped raised me often told me the story of Cossacks raiding her small Lithuanian village at the turn of the 19th century and killing and maiming many of her friends and neighbours as she and her family huddled in the potato cellar. The story was so vivid to her and almost transferred like a copy of a movie that I have been able to recall it as one would watch an old movie.

Many of my patients are Holocaust survivors. They are often plagued with distant horrific memories that are so vivid when recounted or when they intrude into consciousness that they become agitated, fearful and panicked. They actually believe they are reliving the painful associations with that previous part of their life, which they may have spent many years trying to forget. One of my patients who had been incarcerated in a concentration camp in Poland would recount to his wife in total terror and remorse how he managed to avoid being taken out of the morning roll call on a freezing morning to be shot, but the man, in fact a friend, standing next to him was taken and murdered instead. He kept repeating to his wife, "they took him instead of me, they should have taken me, they should have taken me." His wife said that no matter what she said to him he would not get out of that frame of mind which he told with terror on his face over and over again until he was quite exhausted. Even the use of various medications, eventually resulting in small doses of atypical neuroleptics did not eliminate the experience even though it modified the intensity of his very emotional outbursts. The response to SSRIs and beta-blockers both of which were tried was not impressive. http://www.nature.com/drugdisc/news/articles/436448a.html

With this conscious awareness of how some people, seem to have the propensity to relive certain experiences with great vividness, I was enthralled to see a report in the Journal of Cognitive Neurosciences describing a study using complex FMRI imaging techniques that may help to explain the neurophysiology of vivid memory recall. From this study, undertaken at the Rotman Research Centre of Baycrest with Dr. Bradley Buchsbaum as the primary investigator that it appears the brain keeps in its memory the pathways of different experiences (http://www.sciencedaily.com/releases/2012/07/120723134745.htm). These, when accessed, can repeat the circuitry of the original experience so that the memory is as if that sequence of events is taking place as vividly as in "real time." If this is shown on further studies to be the mechanism for vivid memories, it potentially opens up new ways to treat or prevent vivid memories of terrifying experiences and perhaps even play a role in addressing the mental experience of post-traumatic stress disorder. This observation opens up many avenues for future research and perhaps interventions that may prove therapeutic beyond the current typical cognitive and other combinations of therapies. (http://www.helpguide.org/mental/post_traumatic_stress_disorder_symptoms_treatment.htm).

Derived from article in Canadian Jewish News February 28, 2013.

I returned from a medical conference overseas. As I entered the living room, I could see the small walnut side table my wife emailed me about while I was away. It was placed in front of the gas fireplace, next to my favourite "relax" chair and was the perfect colour and size to fit there, waiting for a cup of coffee, a portable phone and the controller for the small stereo next to it. I marvelled at the shape and fine workmanship reflecting that even after less than one term in a College course in industrial woodworking my son Eytan, whose primary love is playing the electric guitar with his heavy metal music band, was able to do such lovely work. His taking a college course in woodworking was part of his desire to have some other skills beyond music for the future and working with wood has always been attractive to him. Three months later at the end of his second term as a gift he made two small tables for our sun room out of extraordinary Walnut with Olive Ash Burl (Figure 1).

Figure 1. Walnut with Olive Ash Burl Tables

The quality was very impressive but most important when I asked him how he did it he was able to go through all the steps with hand drawings to illustrate. Clearly for him the wood, the design and the hands-on experience were very meaningful.
Of the many reasons I was so delighted with his handiwork was the associations I had with woodworking. I attended New York's unique Brooklyn Technical High School because during my early teenage years I wanted to be an engineer like my late father. I loved building and fixing things and had ability in math and physics, therefore, it seemed a natural career path. "Tech" as the school was called by the students was a fantastic educational experience. Beyond a vigorous general curriculum we averaged an extra two hours a day of technical skills and processes which ranged from working with the various metals and wood. I recall vividly my woodworking teacher who was demonstrating how to use a chisel properly. It was from him I learned that a sharp tool is much safer than a dull one as you do not have to apply as much pressure which can lead to poor tool control. I recall how after he chiselled a piece of wood and before it was actually sanded he let us all feel the surface and said something which then would have been considered a bit risqué, "see, smooth as a baby's aaaarm", at which we all sniggered, knowing what "a" word he really meant.

I changed career plans at the end of high school and decided on medicine which was the perfect choice for me. I have however always maintained my love and respect for working with wood. When I did my military service in Israel I had access to a large "hobby shop" which had all the woodworking machines and tools I learned to use at "Tech". With ample supplies of rough wood from the crates in which new General Electric airplane engines were shipped to replace original French engines in reconfigured old French fighter planes I was able to build kitchen shelving and cabinets and furniture for our future Jerusalem apartment.

I once saw a house for sale in which the husband as part of his retirement project renovated it using hand turned and carved and stained wood wherever there was an opportunity to do so. The project according to his wife, kept him sane, healthy and active for the fifteen years since his retirement. His experiences with woodworking are echoed by many patients who have pursued "hobbies" or "pastimes" from their younger years and use them as a focus of their creativity to give meaning and passion to their post-retirement years.

There is a body of evidence and knowledge that supports the concept that working with wood can be a very meaningful activity for those living with dementia, especially if their past experience included working with wood as part of their employment life or one of their hobbies. There is often an exaggerated concern that using the tools necessary to work with wood might be potentially dangerous for those living with dementia depending on their degree of residual capability. It is known that skills from the past are often preserved even as the degree of cognitive impairment progresses. Choosing what types of tools or machines might no longer be within the realm of safety would be a prerequisite for designing woodworking programs of seniors living with dementia. An example of one such program describes the program of "Easy Woodworking for seniors with Dementia". In it is described the parameters for success, "Though long-term care residents with dementia may have short-term memory impairment, wooden craft kits are a good way to provide sensory stimulation and creative outlet without requiring a high degree of skill or even memory. From picture frame kits to wind chimes, bird feeders to Christmas ornaments, these wooden crafts can be painted and assembled in one or two sessions with the help of volunteers or even grandchildren who participate in the fun." (http://www.ehow.com/info_8508900_easy-woodworking-projects-elderly.html)

In an academic study on "Tailored Activities Program (TAP) it was determined that if the correct steps are taken to assess and implement activities according to the individual person's cognitive and physical abilities and past history of interests many activities (including woodworking) can be designed that will provide the individual with a meaningful and satisfying activity while at the same time decreasing care-giver burden and decrease the level of neuropsychiatric behavours. In their article published in the 2008 American Journal of Psychiatry "Tailored Activities to Manage Neuropsychiatric Behaviors in Persons with Dementia and Reduce Caregiver Burden: A Randomized Pilot Study" the authors, Laura N. Gitlin LN, Laraine Winter L, Janice Burke J, et al., concluded the following: "In summary, this study provides compelling evidence that a tailored approach that taps residual abilities and previous roles and habits improves life quality in dementia patients. This study identifies a process for customizing activities to abilities and training families in use of activities in daily care. Teaching caregivers activity use has added value by reducing their objective burden and enhancing skills. Given that pilot studies tend to yield large effect sizes, and that the control group did not evince benefit in all areas as the experimental group after treatment receipt, it is important to test TAP on a larger scale, validate it with diverse dyads, and examine the underlying physiological mechanisms by which symptom reduction occurs."http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2803044/

Conclusion
What does the finding that woodworking, whether started in one's early years or not, can be employed to promote a sense of well-being and creativity and accomplishment in individuals living with dementia mean for those designing programs for those in need of long-term care or those attending day programs in the community? Is woodworking unique among a range of creative activities that require the use of manual dexterity, multi-tasking and a degree of problem solving or is it like other similar activities in the realm of arts and crafts. Does the challenge of creating an adequate space with the necessary tools and proper supervision required for woodworking to occur preclude most facilities or community programs for offering such activities to those inclined to take it on? It would seem that considering the potential and real benefits from woodworking as part of the spectrum of creative activities it should be part of the agenda for recreational coordinators or planners to consider when developing programs for those living with dementia.

From my own experience and from what I am observing from the reaction to woodworking in my son, wood resonates for many because of its historical associations in one's life as well as for its marvellous textures and smells. Whether it is painting, ceramics, knitting, quilting, photography or woodworking, the satisfaction of working with one's hands and brain is wonderful for the mind and the soul.

Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Late-Stage Dementia: Promoting Comfort, Compassion, and Care and previous two books being Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com

When just getting started with woodworking, it can be challenging to know where to start or find a project that is actually suitable for beginners. That's why I spent time researching, pulling together, and creating a go-to guide focused on 50 simple DIY woodworking projects that are perfect for new woodworkers: 50 Small, Simple, & Easy Beginner Woodworking Projects