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July 27th, 2008

I cannot get over how amazing this blog is. The entries are good, but the comment threads are unreal.

http://newoldage.blogs.nytimes.com/2008/07/24/love-in-unexpected-places/

The author describes her experiences with a particular nursing home for her mother, and a particularly wonderful person who works there. A lot of the comments are from people who similarly had loved ones in _that particular nursing home_, which all by itself is really kinda cool (more cool if I were shopping for a nursing home for someone in the NYC area, but this is all very theoretical for me anyway) since there's reason to believe you're really looking at apples-to-apples. Some of the comments are about parallel experiences (good, bad and indifferent) in other locations. But there's some fantastic analysis embedded in these personal, detailed stories.

I suppose the first thing that jumps out is the repeated recommendation to hire a private aide for your loved one. There's dispute about the relative merits of private vs. semi-private rooms, but no one is arguing against having a private aide. There's a parallel here in my world: the recommendation to hire a doula, because the nurses aren't there to help you or be with you -- they are hired to supply particular medical procedures and that's it. Same thing in nursing homes, apparently.

The next thing that jumps out is that virtually everyone in an nursing home has some fairly significant cognitive impairment -- and they don't wind up in the Special Wing until they're way, way far gone. Not necessarily Alzheimer's, but someone who put someone in a nursing home for Lyme Disease recovery with the expectation of them coming back out were quite horrified about how nursing homes weren't really set up for anything _but_ end-of-life and end-of-life with a lot of cognitive impairment at that.

It had been increasingly clear that everyone was keeping their loved ones in assisted living as long as possible before being forced to switch to nursing homes, and the One Thing that forced the change was advanced dementia of one form or another resulting in them being more or less evicted from assisted living. Makes sense that the result would be that nursing homes would ONLY have that group after a while.

The other thing that jumps out -- I make have remarked on this before -- is how how many people basically shudder and go, I'd rather _die_ than have that happen to me (especially if they've watched one or more relatives go down in a nursing home), and here's _my_ plan for making sure I get to exit ahead of time.

Comment #14 is an interesting variant of the usual:

"one does not need to hoard pills to use all at once. If one can restrict one’s eating…to essentially starve oneself, that is a quick low pain way to go. My mother had investigated it when she was in her 80s…and the knowledge brought her relief that she would be able to take matters into her own hands if need be. Sadly, 2 months later a stroke did it for her, before she wanted to die."

While of course I am sad to hear that this woman's mother didn't get to pick her way out, and sad for the daughter because it's gotta be tough to lose someone you love, I just have to marvel at the idea that it could be considered sad to die of a stroke (and apparently not a lingering one, which _would_ have been pretty awful) while in one's 80s, _after_ planning one's death, but before being able to implement it. Parallels here in the world of childbirth as well, in that I find myself completely unable to empathize with some tales-of-woe (the one in _The Mask of Motherhood_ springs to mind, IIRC), when at least all the details supplied would have qualified as a fantastic birth experience from my perspective. Similarly, done in by a quick stroke at that age? Woo fucking hoo! I would consider that hitting that jackpot.

There's another story in the comments raging about neglect of a loved one in the nursing home, someone on dialysis who died of an undiagnosed infection. _Again_, if you're on _dialysis_ in a _nursing home_, given your options, this might be one of the better ways out. Please don't misunderstand me. I'm _sorry_ about people who lose a loved one. I'm _sorry_ that people die. And if the comments are just ordinary grief and loss that have been redirected to the technical details, I guess I can shrug and say, that's just human. But if this kind of thinking is setting policy somewhere, I'm a bit concerned.

ETA: Given the vast quantities of money being spent on care for the people in nursing homes, and given that there's quite a lot of consensus (other than the I'm-gonna-die-before-I-land-there crowd) that we should spend money to make it a better experience all 'round, I think we should, collectively, quit wondering about several otherwise inexplicable things in other times and places: (a) the Pyramids, (b) Stonehenge and (c) Buddhist Funerals in Japan. There are some other examples, closer to home, that would probably be a bit touchy to mention. We all engage in ancestor worship, one way or another. After a while, you don't need to understand why; you just need to recognize it in action.

ETA2: Looks like George is treating the comments section as an opportunity for some hooking up. *Highly* entertaining.

ETA3: Comment #30 by "Sere" indicates I am not alone in reading and enjoying this blog for somewhat unusual reasons (altho I do not share Sere's particular explanation). After noting she is not old, and is an orphan with no parents to worry about, Sere says:

"I read this blog for the strange pleasure of a rare thing: reading healthy people’s fantasies of death...Children wishes for their parents’ demise, and dreaming of a swift and easy death for themselves."

Sere isn't being sarcastic or mean (as near as I can tell), but utterly sincere and I really love that. I've been trying to figure out why _I'm_ so taken by this blog. Obviously, when people are telling a lot of details about a subject little spoken of but close to the heart, what's not to love? But I think it's more. I've always thought a lot about the future and a lot about death. My planning for the future (which coexisted, bizarrely, with long-standing suicidal ideation) has projected forward-from-now until fairly recently. But lately, I've been thinking a lot more in terms of go-to-the-end-and-work-backwards. I think it's because I've gone, in the last few years, from thinking in terms of, if stagflation happens, the money might run out to, hey, we're dealing with a really dodgy economic environment, I should pay a lot more attention to the consequences to my family. And I know from nothing, personally, about nursing homes, since my grandparents all died at home, one way or the other, and my other relatives who have died have not spent more than a few months in nursing care, if that.

CT scan coverage continues

R. pointed me at this one:

http://www.nashuatelegraph.com/apps/pbcs.dll/article?AID=/20080727/NEWS01/925050047

I saw this one last month:

http://www.nytimes.com/2008/06/29/business/29scan.html

Short form: Lots o' people doing CT scans, for pretty dubious reasons. Some doctors are trying to slow the process down. If they start sending you for lots of imaging (like, more than one, maybe, more than five definitely) you probably want to start dragging your heels and asking a _lot_ of questions.

rambling about regulation

Looks like the, hey, we're in this mess because the regulators weren't regulating meme is starting to gain a little traction.

http://norris.blogs.nytimes.com/2008/07/23/will-wall-street-sober-up/

From the comments (which are pretty erratic -- not as good as the New Old Age, but better than Freakonomics, which says stunningly little):

http://polecolaw.blogspot.com/2008/07/i-have-been-following-and-writing-about.html

I've been thinking a bit more about the nasty little hole we are in, and come to a few conclusions. We _did_ have a bunch of regulations, and the regulations had a variety of costs associated with them. As our recollection of the problems the regulations were successfully preventing receded, we started to believe in things like "the end of the business cycle". The costs of those regulations didn't make sense any more, because we couldn't perceive the benefit (pro-vaccine folk argue similarly, I might note, without here taking a stance either in general or in specific about vaccines).

As _individuals_, the best way to deal with macroeconomic changes is to attempt to predict them (pretty impossible, basically) and/or insulate ourselves from the worst of those effects. Generally speaking, the goal here is to be able to outrun the other people who are being chased by the bear. Needless to say, collectively -- as policy, that's kinda gross/creepy/inappropriate/just plain wrong.

When you try to analogize from personal "responsibility" to policy, you run into problems.

As long as we were still regulating, but just doing less of it, things got more cyclical and unstable in a relatively smooth way. But in the last several years, our leaders have explicitly taken the stance that Regulation is Wrong and put people in charge of enforcing the regulations who have as a personal political goal undermining those regulations. You could get into why -- personal benefit, ideology, whatever -- but that's what has been happening.

The smart folk, of course, are just trying to Outrun the Bear and the mean smart folk are busy blaming everyone else for not running as quick, and some really evil folk (smart or otherwise) are busy trying to get others to stop running. Spend that rebate check. Buy a house. No, don't swap that SUV for a Mini Cooper. Etc.

So as an individual, trying to predict the future so I can outrun the bear or be a long ways away from the bear or whatever seems appropriate, things look really bad and really impossible to recover from. But if I look at this problem from a policy perspective and STOP trying to predict the future but instead try to change the present, the problem is unbelievably straightforward.

Make the banks write down the bad loans. If you have to bail out the depositors, fine, but make sure the executives and the shareholders get absolutely nothing until after the problem they created is fixed. It's worse for everyone if all those houses wind up unoccupied; try to find a way to stop the freefall before it goes that far. And don't raise the limit on FDIC insurance until _after_ this whole thing is fixed.

Prosecute regulators who failed to do their jobs. Make deals with people who can document that they were ordered to do (not do) thus-and-such; go after the big fish preferentially. Don't just let a new election wash all this crap away. Because there is no sink big enough to absorb this crap.

Fuel costs high? Create national programs to reduce our usage now and going forward. Climate change in progress? Ditto to switch over to low or no carbon options. Direct technological development to enable us to need less "base load", since that seems to be the big stopping point on wind/solar and to improve battery technology, since that helps with base load and may help solve our transportation issues.

Instead of trying to bail out industries or corporations which have been large parts of the US economic system but are increasingly inappropriate, find a way to clear a way for them to finish toppling. They're going down; get everyone out of the way.

(Get out of unnecessary wars. Apologize for being a jackass. Work with the international community of nations in a humble and deferential way.)

And while we're doing all that, see if we can't find some way to deal with demographic shrinkage. It isn't just about financing retirement -- it isn't even just about paying the bills on nursing care at end of life. We need to figure out a way to supply more humane care at end of life. It's not at all clear what that means from a policy perspective (I know what the individual solution is: big pile o' dough and shorten the end-of-life process as much as possible -- but those solutions aren't necessarily good policy), but I suspect it means recognizing that we need a lot of bodies to take care of all the bodies, and everyone needs to have their needs met. As long as anyone sees a profit opportunity here -- whether it's for CT scans or new and better drugs or mammograms for 85 year olds -- we won't be doing the cheapest/best job we can in this area. It's fine if it looks like a place to have a nice, stable, won't-get-rich-but-won't-starve-either career -- sort of like being an elementary school teacher. And maybe that should be the goal. Otherwise, I foresee a fork in the road where we're either all spending some years of our life "volunteering" in this field or accepting assisted suicide if not euthanasia on a grand scale. Or more of the same: a few people get very expensive care, a lot more people get care that makes everyone unhappy and is still pretty expensive, and every year, more and more younger people go without any care at all.
http://www.boston.com/news/local/new_hampshire/articles/2008/07/27/nh_woman_dies_of_injuries_from_june_scooter_crash/

That's pretty sad. Given how many people die in SUV rollovers or other automobile crashes, I'm not saying this is an argument _against_ scooters or other two-wheelers. Nevertheless, that's pretty sad.
http://www.boston.com/bostonglobe/magazine/articles/2008/07/27/too_tight_or_just_right/

"Helicopter" is acknowledged but almost as quickly dismissed.

Fantastic!

I know there are families that are horribly dysfunctional and don't let their kids grow up and so forth. But not all parents who stay close to their kids are crazy in _that_ way. And it's amazing to finally see someone write about this in a non-hostile/non-mocking way.

Wonders will never cease.