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Slow Medicine: Slow Medicine: ReRe--balancing Eldercarebalancing Eldercare
Dr. Dennis McCulloughDr. Dennis McCulloughDartmouth Medical SchoolDartmouth Medical SchoolHanover, New HampshireHanover, New Hampshire
Eldercare, a World of DilemmasEldercare, a World of Dilemmas
Evaluating and managing cognition Evaluating and managing cognition impairmentimpairment
Depression....or not...Depression....or not...
StrokesStrokes----ancient small bigancient small big
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StrokesStrokes ancient, small, big...ancient, small, big...
Driving...Driving...
POLST, MOLST, COLST...POLST, MOLST, COLST...
Polypharmacy / overmedication...Polypharmacy / overmedication...
Money / time Money / time
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Why Slow Medicine?Why Slow Medicine?
ComplexityComplexityp yp y
Fragmentation of CareFragmentation of Care
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FRAGMENTATION OF CAREFRAGMENTATION OF CARE
More and more “More and more “--ists”ists” SpecialSpecial--istsists
HospitalHospital--istsists
TransitionTransition--istsists
SNFSNF--istsists
LTCLTC--istsists
OfficeOffice--istsists
HomeHome--istsists
Palliative carePalliative care--istsists
HospiceHospice--istsists
IncidentalomaIncidentaloma--istsists
The Medical Model The Medical Model / Social Model / Social Model
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InterfaceInterface
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BackgroundBackground
PACEPACE
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EvercareEvercareMedicaid WaiverMedicaid Waiver
Kendal retirement communityKendal retirement community
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SLOW MEDICINE’S SLOW MEDICINE’S FIVE FIVE
FOUNDATIONFOUNDATION
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FOUNDATION FOUNDATION STONESSTONES
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I.I.
AGING EDUCATIONAGING EDUCATION----How How do we orient ourselves, our do we orient ourselves, our
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,,communities, our patients and communities, our patients and
families (in an agingfamilies (in an aging--averse averse society)?society)?
1010
II.II.
DEPENDENCY (and interDEPENDENCY (and inter--
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dependency)dependency)----challenging challenging individualism: the New Ethics individualism: the New Ethics
of Eldercareof Eldercare
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III.III.
COMMUNICATIONCOMMUNICATION----Shifting Shifting
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from Information Giving to from Information Giving to Active Listening Active Listening
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IV.IV.
COVENANTAL CARE AND COVENANTAL CARE AND
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ADVOCACY (in the face of ADVOCACY (in the face of failing Primary Care)failing Primary Care)
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V.V.
THE PRIMACY OF THE PRIMACY OF
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KINDNESS (in our hurried KINDNESS (in our hurried world).world).
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The Journey of Late LifeThe Journey of Late Life
StabilityStability
CompromiseCompromise
DeclineDecline
Prelude to DyingPrelude to Dyingpp
CrisisCrisis
RecoveryRecovery
y gy g
DeathDeath
Grieving / LegacyGrieving / Legacy
StabilityStability
CompromiseCompromise
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CrisisCrisis
RecoveryRecovery
DeclineDecline
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Prelude to DyingPrelude to Dying
DeathDeath
Grieving / LegacyGrieving / Legacy
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WHAT ISWHAT ISSLOW MEDICINE?SLOW MEDICINE?SLOW MEDICINE?SLOW MEDICINE?
FAST FOOD / FAST FOOD / SLOW FOODSLOW FOODSLOW FOODSLOW FOOD
SLOW CITIESSLOW CITIESSLOW TRAVELSLOW TRAVELSLOW MONEYSLOW MONEYSLOW MONEYSLOW MONEY
SLOW PARENTINGSLOW PARENTING
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LOCAL INGREDIENTS, LOCAL INGREDIENTS, FAMILY RECIPESFAMILY RECIPESFAMILY RECIPESFAMILY RECIPES
CULTURAL CONTEXT AND CULTURAL CONTEXT AND PATIENT AND FAMILY PATIENT AND FAMILY
VALUESVALUES
SIMMERING ON THE BACK SIMMERING ON THE BACK BURNERBURNERBURNERBURNER
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PACING ALL ELDERCARE PACING ALL ELDERCARE DECISIONSDECISIONSDECISIONS DECISIONS
BIG TABLE, LONG MEALSBIG TABLE, LONG MEALS
ENLARGING SUPPORT, ENLARGING SUPPORT, S S A G A OCACS S A G A OCACSUSTAINING ADVOCACYSUSTAINING ADVOCACY
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Slow MedSlow Med 176.6176.6 62.762.7
Comp 1Comp 1 217.7217.7 187.l187.l
Comp 2Comp 2 209.9209.9 187.9187.9
Hospital Admissions / 1,000 enrollees Hospital Admissions / 1,000 enrollees /yr/yr
Comp 3Comp 3 260.7260.7 142.7142.7
Comp 4Comp 4 272.9272.9 182.2182.2
Comp 5Comp 5 292.8292.8 289.7289.7
DARTMOUTH ATLASDARTMOUTH ATLAS——UNPUBLISHED DATAUNPUBLISHED DATA
Other outcomes studiedOther outcomes studied
Surgical admissionsSurgical admissions--no changeno change
Medical admissionsMedical admissions--decreaseddecreased
ER visitsER visits--decreaseddecreased
EOLEOL——hospital days, ICU days, physicians hospital days, ICU days, physicians seen, specialists seen, hospital revenuesseen, specialists seen, hospital revenues——in 3 in 3 years preceeding deathyears preceeding death--decreased decreased
Elder and family satisfactionElder and family satisfaction--increasedincreased
In our quest for quality in the In our quest for quality in the late years of life, Slow late years of life, Slow
Medicine brings together the Medicine brings together the best “medical caring” with ourbest “medical caring” with ourbest medical caring with our best medical caring with our ageage--old traditions of support old traditions of support
and caring for elders and their and caring for elders and their families.families.
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My Mother, Your Mother: My Mother, Your Mother: Embracing “Slow Medicine” the Embracing “Slow Medicine” the
Compassionate Approach to Caring Compassionate Approach to Caring for Your Aging Loved Onesfor Your Aging Loved Ones
Dennis McCullough, M.D.Dennis McCullough, M.D. www.MyMotherYourMother.comwww.MyMotherYourMother.com
SLOW MEDICINE SUGGESTED READING—Spring [email protected]
A History of Old Age, Edited by Pat Thane, London: Thames and Hudson, 2005.
Athill, Diane, Somewhere Towards the End, New York: W.W. Norton, 2008
Bynum, J., D. McCullough et al, “A Medical Home where the Patient Lives: Collaboration between Primary Care Providers and Continuing Care Retirement Communities”, Health Affairs, May 2011.
Gawande, Atul, “Letting Go”, The New Yorker, August 2, 2010.
Gross, Jane, A Bittersweet Season: Caring for Our Aging Parents--and Ourselves, New York: Knopf, 2011.
Kleinman, Arthur, “On Caregiving”, Harvard Magazine, July-August 2010.
McCullough, Dennis, My Mother, Your Mother: Embracing “Slow Medicine”, the Compassionate Approach to Caring for Your Aging Loved Ones, New York: HarperCollins, 2008.
Morrison, Mary C., Let Evening Come: Reflections on Aging, New York: Doubleday, 1998.
Olds, Jacqueline M.D. and Richard Schwartz, M.D., The Lonely American: Drifting Apart in the Twenty-First Century, Boston: Beacon Press, 2009.
Paley, Grace, Fidelity (poems), New York: Farrar, Straus and Giroux, 2008.
Starr, Paul, The Social Transformation of American Medicine, New York: Basic Books, 1982.
The Oxford Book of Aging: Reflections on the Journey of Life, Edited by Thomas R. Cole and Mary G. Winkler, Oxford: Oxford University Press, 1994.
Thaler, Richard H. and Cass R. Sunstein, Nudge: Improving Decisions About Health, Wealth and Happiness, New Haven: Yale University Press, 2008.
Slow Medicine Recommended Movies on Aging
The Trip to Bountiful (1985, Peter Masterson)http://www.imdb.com/title/tt0090203/
The Company of Strangers OR Strangers in Good Company (1991, Cynthia Scott)http://www.imdb.com/title/tt0102993/
Everybody’s Fine (1990, Giuseppe Tornatore)http://www.imdb.com/title/tt0100681/
Wrestling Ernest Hemingway (1993, Randa Haines)http://www.imdb.com/title/tt0108596/
Tuesdays with Morrie (1999, Mick Jackson)http://www.imdb.com/title/tt0207805/
The Notebook (2004, Nick Cassavetes)http://www.imdb.com/title/tt0332280/
Mrs. Palfrey at the Claremont (2005, Dan Ireland)http://www.imdb.com/title/tt0421229/
Away From Her (2006, Sarah Polley)http://www.imdb.com/title/tt0491747/
The Savages (2007, Tamara Jenkins)http://www.imdb.com/title/tt0775529/
Young at Heart (2007, Stephen Walker, Sally George)http://www.imdb.com/title/tt1047007/
Up (2009, Pete Docter, Bob Peterson)http://www.imdb.com/title/tt1049413/