DiversityNursing Blog

Can A Person With Dementia Consent To Sex?

Posted by Erica Bettencourt

Mon, Apr 27, 2015 @ 11:56 AM

INA JAFFE

www.npr.org 

 

hands wide a3025de4d88febec5bad153c15516ab775deac64 s800 c85 resized 600Sexual relationships in long-term care facilities are not uncommon. But the long-term care industry is still grappling with the issue.

CAN A PERSON WITH DEMENTIA CONSENT TO SEX?

There's no greater evidence of that than a criminal case in Iowa. On Wednesday, a jury in Iowa found a 78-year-old man not guilty of raping his wife, who had Alzheimer's disease. Henry Rayhons' wife lived in a nursing home. The staff there told Rayhons that because of her dementia, his wife was no longer capable of consenting to sex. He had been charged with sexual assault for allegedly having sex with her after that.

 

But at the Hebrew Home in Riverdale, N.Y., the fact that some people with dementia still have sex lives isn't news. That facility has had a written policy to help staff manage such relationships for 20 years.

"It was controversial in 1995 and it's controversial today," says Daniel Reingold, the CEO of RiverSpring Health, the nonprofit that runs the Hebrew Home.

"We knew that there was intimacy occurring, and we considered it to be a civil right and a legal right," says Reingold. "We also felt that intimacy was a good thing, that touch is one of the last pleasures we abandon and lose as we age."

Reingold says the policy protects residents from unwanted sexual contact. And he argues that people with dementia are indeed capable of giving consent.

"People who have Alzheimer's disease or dementia are asked on a daily basis to make decisions about their desires," says Reingold, "from what they eat to activities they may want to engage in," including intimacy with another person.

But even with a written policy, it's not that easy for nursing homes to figure out when consent to sex is really valid, says Evelyn Tenenbaum, a professor of law at Albany Law School and bioethics professor at Albany Medical College.

"For example, suppose you have a couple and the woman believes that the man she's seeing is her husband," says Tenenbaum. "Then she consents to a sexual relationship. Is that really consent if she doesn't understand who he is and that she's not married to him?"

Sometimes in such cases, nursing homes will defer to the wishes of the resident's family, says Tenenbaum.

"On the other hand, nursing homes are required to take care of the psychosocial needs of their residents," says Tenenbaum. "Whether psychosocial needs would include sexual relationships is a question."

And it's a question with no commonly accepted answer. The American Health Care Association, a trade group representing the majority of nursing homes, only suggests that its member facilities develop their own policies. Patricia Bach, a geriatric psychologist, says when she started looking into the topic she didn't find much.

"There was very, very little empirical evidence, little data, few research studies and it really was a lower priority issue for long-term care providers," she says.

So with a colleague, Bach surveyed members of the American Medical Directors Association, which represents physicians who work in long-term care facilities.

Bach found that "only 25 to 30 percent actually had formal training in the area of intimacy and sexuality, as it would pertain to older adults. Thirty percent had no training at all." The survey also found that only about 30 percent of nursing homes where the respondents worked had formal policies.

That's something that needs to change, and fast, says Reingold.

"We are dealing with the arrival of my fellow baby boomers," he says. They've "grown up in an environment where sexuality was a much more open conversation and activity."

And there's no reason to think that will change, Reingold says, even when those boomers are in long-term care.

Topics: dementia, patients, elderly, consent, criminal case, medical staff, Alzheimer's disease, sex, sexual relationships, assisted living

New Treatment For Dementia Discovered: Deep Brain Stimulation

Posted by Erica Bettencourt

Mon, Apr 06, 2015 @ 02:04 PM

www.sciencedaily.com

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Pushing new frontiers in dementia research, Nanyang Technological University, Singapore (NTU Singapore) scientists have found a new way to treat dementia by sending electrical impulses to specific areas of the brain to enhance the growth of new brain cells.

Known as deep brain stimulation, it is a therapeutic procedure that is already used in some parts of the world to treat various neurological conditions such as tremors or Dystonia, which is characterised by involuntary muscle contractions and spasms.

NTU scientists have discovered that deep brain stimulation could also be used to enhance the growth of brain cells which mitigates the harmful effects of dementia-related conditions and improves short and long-term memory.

Their research has shown that new brain cells, or neurons, can be formed by stimulating the front part of the brain which is involved in memory retention using minute amounts of electricity.

The increase in brain cells reduces anxiety and depression, and promotes improved learning, and boosts overall memory formation and retention.

The research findings open new opportunities for developing novel treatment solutions for patients suffering from memory loss due to dementia-related conditions such as Alzheimer's and even Parkinson's disease.

This discovery was published in eLife, a peer-reviewed open-access scientific journal published by the Howard Hughes Medical Institute, the Max Planck Society and the Wellcome Trust.

Assistant Professor Ajai Vyas from NTU's School of Biological Sciences said, "The findings from the research clearly show the potential of enhancing the growth of brain cells using deep brain stimulation.

"Around 60 per cent of patients do not respond to regular anti-depressant treatments and our research opens new doors for more effective treatment options."

Dr Lim Lee Wei, an associate professor at Sunway University, Malaysia, who worked on the research project while he was a Lee Kuan Yew Research Fellow at NTU, said that deep brain stimulation brings multiple benefits.

"No negative effects have been reported in such prefrontal cortex stimulation in humans and studies have shown that stimulation also produces anti-depression effects and reduces anxiety.

"Memory loss in older people is not only a serious and widespread problem, but signifies a key symptom of dementia. At least one in 10 people aged 60 and above in Singapore suffer from dementia and this breakthrough could pave the way towards improved treatments for patients."

Growing new brain cells

For decades, scientists have been finding ways to generate brain cells to boost memory and learning, but more importantly, to also treat brain trauma and injury, and age-related diseases such as dementia.

As part of a natural cycle, brain cells constantly die and get replaced by new ones. The area of the brain responsible for generating new brain cells is known as the hippocampus, which is also involved in memory forming, organising and retention.

By stimulating the front part of the brain known as the prefrontal cortex, new brain cells are formed in the hippocampus although it had not been directly stimulated.

The research was conducted using middle-aged rats, where electrodes which sends out minute micro-electrical impulses were implanted in the brains. The rats underwent a few memory tests before and after stimulation, and displayed positive results in memory retention, even after 24 hours.

"Extensive studies have shown that rats' brains and memory systems are very similar to humans," said Prof Ajai who is a recipient of NTU's prestigious Nanyang Assistant Professorship award.

"The electrodes are harmless to the rats, as they go on to live normally and fulfil their regular (adult) lifespan of around 22 months."

The research was funded by the Lee Kuan Yew Research Fellowship which supports and promotes young and outstanding researchers in their respective areas of specialisation.

Topics: science, health, brain, memory, dementia, medical, treatment, deep brain stimulation, brain cells, electricity

Music Ignites Lost Memories in 'Good-News' Film

Posted by Erica Bettencourt

Mon, Jul 21, 2014 @ 01:18 PM

By Kim Painter

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Music has an unmatched power to bring back our pasts. But what if our memories have been lost to Alzheimer's or some other condition? Can music still work its magic?

A new film, Alive Inside, says yes. The film, opening Friday in New York, features the work of Dan Cohen, a New York social worker who started taking personalized iPods to people with dementia in nursing homes several years ago. Cohen's non-profit Music & Memory got a huge boost in 2012 when an early clip from the film, featuring a gentleman named Henry, became an online sensation. It has been viewed more than 10 million times at various websites, filmmaker Michael Rossato-Bennett says.

In the clip, Henry, then 94, is shown slumped and unresponsive in a wheelchair – until a nursing home worker places a set of headphones over his ears. Henry comes alive. He scats along with Cab Calloway and sings a soulful I'll Be Home for Christmas. The music "gives me the feeling of love, romance," he says.

Henry has since passed away, but that clip is one big reason that the Music & Memory program is in 640 nursing homes and assisted-living facilities, Cohen says. He says he won't be satisfied until personalized iPods – loaded with music especially chosen for each participant – are in all 16,000 U.S. nursing homes, available to all 1.6 million residents.

"Ninety-nine percent of these people are still sitting around and doing nothing all day when they could be rocking to their music," he says.

The reasons for Cohen's passion become clear in what Rossato-Bennett dubs "the only good-news film ever made about Alzheimer's." In segment after segment, people with Alzheimer's and other conditions don the headphones, hear the music of their youths and light up. A World War II veteran named John dances in his chair as the Andrews Sisters sing Oh Johnny, Oh Johnny, Oh! Another man holds his wife's hands and sings a duet of Can't Take My Eyes Off of You. An agitated woman becomes serene as she dances to strains of Schubert.

Such scenes are interspersed with comments from doctors, including the neurologist Oliver Sacks, who says, "Music has more ability to activate more parts of the brain than any other stimulus." Others talk about the need to reconnect with lonely, inactive and neglected elders, in and out of nursing homes.

Viewers might come away with the idea that a skillfully loaded iPod is a proven and universally effective cure for all that. In fact, the first big study of Music & Memory is just getting underway in Wisconsin, as part of a state-funded rollout in 200 nursing homes. Researchers will look at whether the approach improves social engagement and reduces agitation, anxiety and depression, say University of Wisconsin-Milwaukee researchers Jung Kwak and Michael Brondino. The study won't focus on memory but will look at overall effects on dementia, Brondino says. One thing they know, he says, is that staffs and patients "absolutely love this program."

The program, which relies on families and aides to work with patients, should not be confused with formal music therapy delivered by professionals trained in that discipline, says Alicia Clair, professor of music education and therapy at the University of Kansas.

Still, she says, "it's a wonderful thing" for many people. Caregivers need to know, she says, that not everyone will respond and that some people can even respond negatively. A song that stirs up sadness or anger might do more harm than good, she says.

Cohen says, "This is not a cure for Alzheimer's, and this does not work for everybody." But, he says, it is something just about anyone can try – something that might open up a whole lost world.

Cohen's tips for setting up an individualized music program and for donating used iPods to the program are at musicandmemory.org.

Alive Inside will open in theaters and be shown in film festivals around the country through mid-September.

Source: http://www.usatoday.com

Topics: music, alzheimers, memories, film, Dan Cohen, social worker, dementia

Singing nurse integrates passions for music, medicine

Posted by Alycia Sullivan

Fri, May 17, 2013 @ 01:40 PM

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Susan Sonnichsen is looking forward to seeing Helen Cross, a patient with dementia who loves hymns. But Cross is having a rough day. Softly, Sonnichsen tells her, “I know something that will make you feel better. How about a song?’’

She starts in with “Joy in My Heart,’’ followed by “Old Rugged Cross’’ and then a favorite, “Amazing Grace.’’ Sonnichsen’s voice fills the space between nurse and patient. Slowly, Cross allows Sonnichsen to take her hand. “OK, we’re getting somewhere,’’ Sonnichsen says, smiling at Cross.

Sonnichsen has been singing ever since she was a kid belting out songs during family road trips. But in her 30 years in nursing, she never knew it could fit into her work. A dementia class for staff at Hospice of the Valley changed all that and today, music is as much a part of her care as is taking a patient’s vital signs.

“They love to sing along,’’ Sonnichsen says. “Even if they’re off key, it’s wonderful to engage them.’’ She prefers old gospel hymns and tunes from popular musicals, but happily takes requests and learns new songs. When a patient is close to death, she sings a lullaby and offers a gentle touch. When a family asks, she gladly sings at patients’ memorials. Some of her colleagues call her the singing nurse.

“Anyone who has enjoyed the experience of hearing Susan sing can attest that her ability to emote through music is a true gift,’’ says Hospice of the Valley social worker Donna Wetzel.

Sonnichsen says integrating her two callings, music and medicine, is a blessing.

“It’s amazing when patients join in with you. It just fills your heart,’’ she says. “It just touches you, makes you feel like that’s why you’re here.’’

Source: AZ Central

Topics: music, singing, dementia, nurse, medicine, healing

How Not to Die

Posted by Alycia Sullivan

Thu, May 09, 2013 @ 02:16 PM

By:  

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Dr. Angelo Volandes is making a film that he believes will change the way you die. The studio is his living room in Newton, Massachusetts, a suburb of Boston; the control panel is his laptop; the camera crew is a 24-year-old guy named Jake; the star is his wife, Aretha Delight Davis. Volandes, a thickening mesomorph with straight brown hair that is graying at his temples, is wearing a T-shirt and shorts and looks like he belongs at a football game. Davis, a beautiful woman of Guyanese extraction with richly braided hair, is dressed in a white lab coat over a black shirt and stands before a plain gray backdrop.

“Remember: always slow,” Volandes says.

“Sure, hon,” Davis says, annoyed. She has done this many times.

Volandes claps to sync the sound. “Take one: Goals of Care, Dementia.”

You are seeing this video because you are making medical decisions for a person with advanced dementia. Davis intones the words in a calm, uninflected voice. I’ll show you a video of a person with advanced dementia. Then you will see images to help you understand the three options for their medical care.

Her narration will be woven into a 10-minute film. The words I’m hearing will accompany footage of an elderly woman in a wheelchair. The woman is coiffed and dressed in her Sunday finest, wearing pearls and makeup for her film appearance, but her face is vacant and her mouth is frozen in the rictus of a permanent O.

This woman lives in a nursing home and has advanced dementia. She’s seen here with her daughters. She has the typical features of advanced dementia …

Young in affect and appearance, Volandes, 41, is an assistant professor at Harvard Medical School; Davis, also an M.D., is doing her residency in internal medicine, also at Harvard. When I heard about Volandes’s work, I suspected he would be different from other doctors. I was not disappointed. He refuses to let me call him “Dr. Volandes,” for example. Formality impedes communication, he tells me, and “there’s nothing more essential to being a good doctor than your ability to communicate.” More important, he believes that his videos can disrupt the way the medical system handles late-life care, and that the system urgently needs disrupting.

“I think we’re probably the most subversive two doctors to the health system that you will meet today,” he says, a few hours before his shoot begins. “That has been told to me by other people.”

“You sound proud of that,” I say.

“I’m proud of that because it’s being an agent of change, and the more I see poor health care, or health care being delivered that puts patients and families through—”

“We torture people before they die,” Davis interjects, quietly.

Volandes chuckles at my surprise. “Remember, Jon is a reporter,” he tells her, not at all unhappy with her comment.

“My father, if he were sitting here, would be saying ‘Right on,’ ” I tell him.

Volandes nods. “Here’s the sad reality,” he says. “Physicians are good people. They want to do the right things. And yet all of us, behind closed doors, in the cafeteria, say, ‘Do you believe what we did to that patient? Do you believe what we put that patient through?’ Every single physician has stories. Not one. Lots of stories.

“In the health-care debate, we’ve heard a lot about useless care, wasteful care, futile care. What we”—Volandes indicates himself and Davis—“have been struggling with is unwanted care. That’s far more concerning. That’s not avoidable care. That’s wrongfulcare. I think that’s the most urgent issue facing America today, is people getting medical interventions that, if they were more informed, they would not want. It happens all the time.”

Unwanted treatment is American medicine’s dark continent. No one knows its extent, and few people want to talk about it. The U.S. medical system was built to treat anything that might be treatable, at any stage of life—even near the end, when there is no hope of a cure, and when the patient, if fully informed, might prefer quality time and relative normalcy to all-out intervention.

In 2009, my father was suffering from an advanced and untreatable neurological condition that would soon kill him. (I wrote about his decline in an article for this magazine in April 2010.) Eating, drinking, and walking were all difficult and dangerous for him. He ate, drank, and walked anyway, because doing his best to lead a normal life sustained his morale and slowed his decline. “Use it or lose it,” he often said. His strategy broke down calamitously when he agreed to be hospitalized for an MRI test. I can only liken his experience to an alien abduction. He was bundled into a bed, tied to tubes, and banned from walking without help or taking anything by mouth. No one asked him about what he wanted. After a few days, and a test that turned up nothing, he left the hospital no longer able to walk. Some weeks later, he managed to get back on his feet; unfortunately, by then he was only a few weeks from death. The episode had only one positive result. Disgusted and angry after his discharge from the hospital, my father turned to me and said, “I am never going back there.” (He never did.)

What should have taken place was what is known in the medical profession as The Conversation. The momentum of medical maximalism should have slowed long enough for a doctor or a social worker to sit down with him and me to explain, patiently and in plain English, his condition and his treatment options, to learn what his goals were for the time he had left, and to establish how much and what kind of treatment he really desired. Alas, evidence shows that The Conversation happens much less regularly than it should, and that, when it does happen, information is typically presented in a brisk, jargony way that patients and families don’t really understand. Many doctors don’t make time for The Conversation, or aren’t good at conducting it (they’re not trained or rewarded for doing so), or worry their patients can’t handle it.

This is a problem, because the assumption that doctors know what their patients want turns out to be wrong: when doctors try to predict the goals and preferences of their patients, they are “highly inaccurate,” according to one summary of the research, published by Benjamin Moulton and Jaime S. King inThe Journal of Law, Medicine & Ethics. Patients are “routinely asked to make decisions about treatment choices in the face of what can only be described as avoidable ignorance,” Moulton and King write. “In the absence of complete information, individuals frequently opt for procedures they would not otherwise choose.”

Though no one knows for sure, unwanted treatment seems especially common near the end of life. A few years ago, at age 94, a friend of mine’s father was hospitalized with internal bleeding and kidney failure. Instead of facing reality (he died within days), the hospital tried to get authorization to remove his colon and put him on dialysis. Even physicians tell me they have difficulty holding back the kind of mindlessly aggressive treatment that one doctor I spoke with calls “the war on death.” Matt Handley, a doctor and an executive with Group Health Cooperative, a big health system in Washington state, described his father-in-law’s experience as a “classic example of overmedicalization.” There was no Conversation. “He went to the ICU for no medical reason,” Handley says. “No one talked to him about the fact that he was going to die, even though outside the room, clinicians, when asked, would say ‘Oh, yes, he’s dying.’ ”

“Sometimes you block the near exits, and all you’ve got left is a far exit, which is not a dignified and comfortable death,” Albert Mulley, a physician and the director of the Dartmouth Center for Health Care Delivery Science, told me recently. As we talked, it emerged that he, too, had had to fend off the medical system when his father died at age 93. “Even though I spent my whole career doing this,” he said, “when I was trying to assure as good a death as I could for my dad, I found it wasn’t easy.”

If it is this hard for doctors to navigate their parents’ final days, imagine what many ordinary patients and their families face. “It’s almost impossible for patients really to be in charge,” says Joanne Lynn, a physician and the director of the nonprofit Altarum Center for Elder Care and Advanced Illness in Washington, D.C. “We enforce a kind of learned helplessness, especially in hospitals.” I asked her how much unwanted treatment gets administered. She couldn’t come up with a figure—no one can—but she said, “It’s huge, however you measure it. Especially when people get very, very sick.”

Unwanted treatment is a particularly confounding problem because it is not a product of malevolence but a by-product of two strengths of American medical culture: the system’s determination to save lives, and its technological virtuosity. Change will need to be consonant with that culture. “You have to be comfortable working at the margins of the power structure within medicine, and particularly within academic medicine,” Mulley told me. You need a disrupter, but one who can speak the language of medicine and meet the system on its own terms.

Angelo Volandes was born in 1971, in Brooklyn, to Greek immigrants. His father owned a diner. He and his older sister were the first in their family to go to college—Harvard, in his case. In Cambridge, he got a part-time job cooking for an elderly, childless couple, who became second parents to him. He watched as the wife got mortally sick, he listened to her labored breathing, he talked with her and her husband about pain, death, the end of life. Those conversations led him to courses in medical ethics, which he told me he found abstract and out of touch with “the clinical reality of being short of breath; of fear; of anxiety and suffering; of medications and interventions.” He decided to go to medical school, not just to cure people but “to learn how people suffer and what the implications of dying and suffering and understanding that experience are like.” Halfway through med school at Yale, on the recommendation of a doctor he met one day at the gym, he took a year off to study documentary filmmaking, another of his interests. At the time, it seemed a digression.

On the very first night of his postgraduate medical internship, when he was working the graveyard shift at a hospital in Philadelphia, he found himself examining a woman dying of cancer. She was a bright woman, a retired English professor, but she seemed bewildered when he asked whether she wanted cardiopulmonary resuscitation if her heart stopped beating. So, on an impulse, he invited her to visit the intensive-care unit. By coincidence, she witnessed a “code blue,” an emergency administration of CPR. “When we got back to the room,” Volandes remembered, “she said, ‘I understood what you told me. I am a professor of English—I understood the words. I just didn’t know what you meant. It’s not what I had imagined. It’s not what I saw on TV.’ ” She decided to go home on hospice. Volandes realized that he could make a stronger, clearer impression on patients by showing them treatments than by trying to describe them.

He spent the next few years punching all the tickets he could: mastering the technical arts of doctoring, credentialing himself in medical ethics, learning statistical techniques to perform peer-reviewed clinical trials, joining the Harvard faculty and the clinical and research staff of Massachusetts General Hospital. He held on to his passion, though. During a fellowship at Harvard in 2004, he visited Dr. Muriel Gillick, a Harvard Medical School professor and an authority on late-life care. Volandes “was very distressed by what he saw clinically being done to people with advanced dementia,” Gillick recalls. “He was interested in writing an article about how treatment of patients with advanced dementia was a form of abuse.” Gillick talked him down. Some of what’s done is wrong, she agreed, but raging against it would not help. The following year, with her support, Volandes began his video project.

The first film he made featured a patient with advanced dementia. It showed her inability to converse, move about, or feed herself. When Volandes finished the film, he ran a randomized clinical trial with a group of nine other doctors. All of their patients listened to a verbal description of advanced dementia, and some of them also watched the video. All were then asked whether they preferred life-prolonging care (which does everything possible to keep patients alive), limited care (an intermediate option), or comfort care (which aims to maximize comfort and relieve pain). The results were striking: patients who had seen the video were significantly more likely to choose comfort care than those who hadn’t seen it (86 percent versus 64 percent). Volandes published that study in 2009, following it a year later with an even more striking trial, this one showing a video to patients dying of cancer. Of those who saw it, more than 90 percent chose comfort care—versus 22 percent of those who received only verbal descriptions. The implications, to Volandes, were clear: “Videos communicate better than just a stand-alone conversation. And when people get good communication and understand what’s involved, many, if not most, tend not to want a lot of the aggressive stuff that they’re getting.”

Even now, after years of refinement, Volandes’s finished videos look deceptively unimpressive. They’re short, and they’re bland. But that, it turns out, is what is most impressive about them. Other videos describing treatment options—for, say, breast cancer or heart disease—can last upwards of 30 minutes. Volandes’s films, by contrast, average six or seven minutes. They are meant to be screened on iPads or laptops, amid the bustle of a clinic or hospital room.

They are also meant to be banal, a goal that requires a meticulous, if perverse, application of the filmmaker’s art. “Videos are an aesthetic medium; you can manipulate people’s perspective,” Volandes says. “I want to provide informationwithout evoking visceral emotions.” Any hint that he was appealing to sentiments like revulsion or fear to nudge patients toward a certain course of treatment would discredit his whole project, so Volandes does all he can to eliminate emotional cues. That is why he films advanced-dementia patients dressed and groomed to the nines. “I give them the nicest image,” Volandes told me. “If with the nicest image we show a huge effect, you can imagine what it would be like if they really saw the reality.”

The typical video begins with Davis explaining what the viewer is about to see, stating plainly facts that doctors are sometimes reluctant to mention. She says, for example: People with advanced dementia usually have had the disease for many years and have reached the last stage of dementia. They are nearing the end of life. The video cuts to a shot of a patient. Then Davis outlines the three levels of care, starting with the most aggressive. Over footage of CPR and mechanical ventilation, she explains that in most cases of advanced dementia, CPR does not work, and that patients on breathing machines are usually not aware of their surroundings and cannot eat or talk. Then she describes limited care and comfort care, again speaking bluntly about death. People who choose comfort care choose to avoid these procedures even though, without them, they might die. She concludes by recommending The Conversation.

It seems a minor thing, showing a short video. As, indeed, it will be, if it happens only occasionally. I didn’t get my head around the scale of Volandes’s ambition until I understood that he wants to make his videos ubiquitous. His intention is not only to provide clearer information but, more important, to trigger The Conversation as a matter of medical routine. “We’re saying, ‘You’re not doing your job if you are not having these conversations in a meaningful way with patients and their families,’ ” he tells me. “If every patient watched a video, there’s standardization in the process. That’s why I call it subversive. Very few things in medicine can change the culture like that.”

Routine use, however, is far, far away. According to Volandes, only a few dozen U.S. hospitals, out of more than 5,700, are using his videos. I spoke with physicians and a social worker at three health systems that are piloting them, and all were very enthusiastic about the results. Volandes is particularly hopeful about a collaboration with the Hawaii Medical Service Association, the state’s dominant health-insurance provider, which is piloting the videos in hospitals, nursing homes, and doctors’ offices. Officials say they hope to expand use statewide within three years. Right now, though, Volandes’s videos have a limited reach.

The problem is not his product but the peculiar nature of the market he wants to push it into. His innovation is inexpensive and low-tech, and might avert misunderstanding, prevent suffering, improve doctor-patient relationships, and, incidentally, save the health-care system a lot of money. He goes out of his way not to emphasize cost savings, partly because he sees himself as a patients’-rights advocate rather than a bean counter, and partly because it is so easy to demagogue the issue, as Sarah Palin did so mendaciously (and effectively) in 2009, when she denounced end-of-life-care planning as “death panels.” Anyone who questions medical maximalism risks being attacked for trying to kill grandma—all the more so if he mentions saving money. For all its talk of making the health-care system more rational and less expensive, the political system is still not ready for an honest discussion. And the medical system has its own ways of fighting back.

Volandes works on his videos ceaselessly. He has curtailed his medical practice and his teaching responsibilities, both of which he misses, and last year gave more than 70 speeches evangelizing for the video project. In an effort to batter the medical establishment into submission with the sheer weight of scientific evidence, he has conducted 13 clinical trials using videos to depict different diseases and situations, and he has seven more studies in the pipeline. He says he gets by on three or four hours of sleep a night. The project has taken over his house. Davis would like her living room back; there are floodlights and a big gray backdrop where her paintings should be.

Volandes thinks he can sustain this pace for perhaps five years—by which time he hopes to have revolutionized American medicine. Davis tries to dial back his expectations, but he resists. “Not when I have nurses and doctors use words liketorture as often as they do,” he says. “In order to make a change, you’ve got to be ambitious. If not, then just publish and get your tenure and move on.”

During my visit, I realized that I had encountered Volandes’s type before, but in Silicon Valley. Volandes has entrepreneurial obsessive-compulsive disorder: the gift, and curse, of unswerving faith in a potentially world-changing idea.

It is not a huge exaggeration to say that obsessive entrepreneurs, from Cornelius Vanderbilt to Steve Jobs, made America great. It is also not a huge exaggeration to say that health care, more than any other nongovernmental sector, has made itself impervious to disruptive innovation. Medical training discourages entrepreneurship, embedded practice patterns marginalize it, bureaucrats in medical organizations and insurance companies recoil from it. And would-be disrupters are generally disconnected from patients, their ultimate customers: they have to take their innovations to physicians, who are notoriously change-averse, and then they must get the government—Medicare, first and foremost—to approve and pay for them. Imagine that Jeff Bezos, when he was starting Amazon, had needed to ask permission from bookstores and libraries.

Volandes, therefore, will fail. That is to say, he will fail if success means revolutionizing the doctor-patient relationship and making The Conversation ubiquitous within five years. Meanwhile, if the American health-care system does not learn how to harness the energy and ideas of people like Volandes, it will fail. Somewhere between those failures lies a path forward. We know medical culture can change for the better; it takes the treatment of pain much more seriously than it used to, for example, and it has embraced hospice care.

The best news about U.S. health care today is that a lot of reform-minded entrepreneurship is bubbling up from within. Volandes is not alone. So many patients and doctors and family members feel marginalized and bureaucratized and overwhelmed that some health systems and insurers, in spontaneous mini-rebellions, are starting to innovate, often on their own dime. I think of Dr. Brad Stuart of Sutter Health at Home, who is building a new late-life-care system that bridges the gap between hospital and hospice, allowing the very sick to receive more care at home; I think of Dr. Derek Raghavan of Carolinas HealthCare System’s Levine Cancer Institute, who is building a “cancer center without walls” that uses telemedicine and other tools to make state-of-the-art treatment available to patients, regardless of where they live. I think of Dr. Woody English of Providence Health and Services, who is 67 and wants to make a difference before he retires. At his instigation, Providence has begun using Volandes’s videos. “The changes will come locally,” English told me, “not nationally.” When I look at him and Volandes and the others, I see not only a test of whether the health-care system’s medical culture can change but also a test of whether itsbusiness culture can change—and that change may, in the end, be even more important.

The morning after the shoot, Volandes shows me some of the footage he plans to use. We watch a patient with advanced Alzheimer’s being fed through a tube that has been surgically inserted into her stomach. An attendant uses a big syringe to clear the tube, then attaches a bag of thick fluid. Over the footage, Davis’s voice will say, Often, people hope tube feeding will help the patient live longer. But tube feeding has not been shown to prolong or improve the quality of life in advanced dementia. Tube feeding also does not stop saliva or food from going down the wrong way.

Volandes is explaining to me that tube feeding is overused in elderly dementia patients, but my mind has floated back to 2009. My father’s disease, by then, had destroyed his ability to protect his airway when he swallowed; food, drink, and saliva ended up in his lungs. He coughed violently when he ate or drank. Doctors mentioned tube feeding as an option, and well-intentioned friends nudged us in that direction. But his friends had no real idea what tube feeding entailed, and neither did I, and neither did he.

“Let me ask you this,” Volandes says. “Suppose I’m having a conversation with you about whether your father would want this. And I said ‘feeding tube,’ and you’re thinking to yourself, Food, yeah, I could give food to my mom or dad. We just want to make sure that regardless of the way the gastroenterologist is presenting the procedure, the patient’s loved ones know this is what we’re talking about.”

Not long before my father died, I asked a hospice nurse about tube feeding. He told me, with grim clarity: “I think that would be cruel.” I remember that nurse with gratitude, because he was right. But “that would be cruel” was not a substitute for The Conversation.

Topics: Boston, dementia, end of life, end of life care, Dr. Angelo Volandes, Massachusetts, video, Aretha Delight Davis

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