Living Wills

I first read about this in the Deccan Herald newspaper. I saw the name Periyakoil (which is a Tamilian name). That got me intrigued about the lady behind the name and so this article began.
For Quartz.

It’s time for Americans to start thinking about how they wish to die

By Shoba Narayan 5 hours ago
Shoba Narayan is a writer in Bangalore. She is the author of “Return to India” and “Monsoon Diary: A Memoir with Recipes.”

The default, if unconscious assumption when you fall ill and are admitted into a hospital is that the doctors will give you the best possible care—that they would do unto you what they would want to have done to themselves. We’d like to think this is true but a new study reveals an area of hypocrisy: a startlingly high percentage of doctors, 88.3% it turns out, do not want high intensity, invasive care at the end of their lives even though they provide such care to their patients.

Indeed, many of them jokingly talk about having “DNR” (Do No Resuscitate) tattooed on their chest, according to Vyjeyanthi S. Periyakoil of the Stanford School of Medicine who is the lead author of the study, “Do Unto Others: Doctors’ Personal End-of-Life Resuscitation Preferences and Their Attitudes toward Advance Directives” published in May in PLOS.

The study raises questions about why medical practitioners make such persistent efforts to prolong the life of hopelessly and critically ill patients while choosing to avoid such a circumstance for themselves. Medical practitioners acknowledge that most aging and critically-ill patients do not want aggressive treatments. Indeed, the Dartmouth Atlas of Health Care indicates that 80% of patients wish to avoid hospitalization at the end of their lives. Yet, in the crisis of the moment, or in the momentum of care that is delivered at ICUs, doctors overrule patient desires when they attempt to save their lives. They subject their terminally ill patients to ventilators, intravenous fluids, tracheostomies, and other procedures that erode the quality of life and personal dignity.

Twenty-five years ago, the Patient Self-determination Act was passed by Congress to help the elderly and medically ill determine what kind of treatments and procedures they wished to allow, or avoid, when they became ill. Also called advance directives or living will, the protocol nudged people into thinking about the level of invasive care they were willing to tolerate if they were to become terminally ill.

The act spawned a cottage industry that sought to help people come up with legal documents that combined a living will with a durable power of attorney. Although it differs by state, today most hospitals are mandated to help elderly and/or terminally ill patients sign advance directives as part of the hospital admission procedure. But hospitals aren’t mandated to follow these directives; therefore, patients don’t necessarily receive the kind of care they want.

The problem often begins at home before aging or terminally ill patients enter the hospital. Surveys by the California Health Foundation show that, while 70%-80% of Americans want to die at home, less than one third of people have talked to a loved one about how they wish to die. Fewer still have actually thought about and written down advance directives. Most terminally ill patients want palliative care that focuses on comfort and dignity, rather than invasive, aggressive treatments. Without prior consideration, in the absence of a pre-written living will, patients are forced to come up with advance directives while admitted into hospitals. The 15 minutes they spend with doctors during this process does not provide enough time to chalk out a treatment plan when things get worse.

As America ages, conversations about how we live; how long we live; and how we die are becoming increasingly (and painfully) resonant in many families. Many of us are caring for octogenarian and older parents, in-laws, aunts and uncles who are physically disabled and some who are terminally ill. The situation is only going to escalate: According to a report from the US Census Bureau, the number of Americans aged 90 and older has nearly tripled since 1980, reaching 1.9 million in 2010 and growing to more than 7.6 million over the next 40 years. This “silver tsunami” of older adults is the largest public health challenge facing society today.

The first order of business, many feel, is to actually get the elderly to make up a living will. The nonprofit organization, Aging with Dignity came up with Five Wishes, a program that helps people make detailed and tough choices about how they wish to be treated at the end of their lives: how long they wished to be sustained if they went into a coma; whether they wished to be on life support; whether they wish to be resuscitated; the level of pain medication they wanted; whether they wanted a cold moist cloth put on their foreheads if they had a fever; whether they wished to be held or not; whether they wanted someone praying by their bedside or not.

Websites such as Mydirectives do the same thing and help people formalize their choices into a legal document. The fundamental question all these documents ask is one we’re afraid to ask: how do you wish to die?

Hardly anyone wishes to die in a hospital. “It takes the heart out of dying,” as Periyakoil said in an interview with 1:2:1 podcast from the Stanford School of Medicine, “the organ becomes more important than the individual.”

However, hospitalization has become the first and default choice in our society. Today, hospices or palliative care is often the last resort because of the number of sub-specialists involved and the fragmented nature of healthcare. This may change, given rising healthcare costs. According to the Dartmouth Atlas of Healthcare, “older Americans account for an estimated 32% of the total Medicare spending on costs related to repeated hospitalizations in the last two years of their life and higher spending has not been associated with better health outcomes.”

As Arnold Relman’s poignant article, “On breaking one’s neck,” points out, hospitals are very good at not allowing people to die. What they don’t do as well is addressing questions of personal dignity and patient comfort. Doctors too, are squeamish about death and dying; and are often uncomfortable about discussing these issues with patients. Indeed, as Benjamin W. Corn writes, most doctors are not emotionally equipped to confront such questions, preferring to act and direct rather than sit and listen. Perhaps the time has come to cease playing ostrich and think about the patient’s quality of death in addition to his quality of life.

Follow Shoba on Twitter @ShobaNarayan. We welcome your comments at ideas@qz.com.

Women’s role

Rewrote this many times.  Interesting topic.

Why doesn’t Priyanka Gandhi reach for the national office that could be hers for the taking?

The Good Life | Shoba Narayan

Priyanka Gandhi Vadra is a magnificent campaigner. In terms of sheer charisma, she beats her brother hollow. She has that preternatural ability to gauge the pulse of the people. It is much more than empathy—every good spiritual guru has empathy. The currency of campaign politics, however, is connecting to a crowd and giving voice to their dreams. It is the ability to deliver the same feel-good factor to a crowd that empathy offers to an individual. This emotional connect combined with force of personality equals charisma. Indira Gandhi wasn’t born with it but she developed this quality. Her granddaughter has it in spades, and yet, she doesn’t use it nearly enough. What is Priyanka afraid of? Why doesn’t she reach for the national office that could be hers for the taking?

Facebook chief operating officer Sheryl Sandberg says that women aren’t ambitious enough. They compromise before they need to. They opt to be dentists rather than surgeons because dentistry offers more work-life balance—this at age 20, before they’ve met their spouse. They put off their childhood dream of starting a school or a restaurant because they are busy helping their husband fulfil his dream—and holding the family together while he does. Women rein in their ambition because they believe success will come with costly sacrifices. Worst of all, many women don’t even try; they don’t “lean in”, as Sandberg says. They compromise from the get-go. Why?

 

Charismatic: If she chooses, Priyanka Gandhi could have a role model in Sarojini Naidu. Photo: Atul Yadav/PTI

Charismatic: If she chooses, Priyanka Gandhi could have a role model in Sarojini Naidu. Photo: Atul Yadav/PTI

 

Bangalore-based Sujata Keshavan, founder of Ray+Keshavan, one of India’s top design firms, believes that it may have to do with economics— and perhaps genetics. She talks about how difficult it was for her to persuade young women to continue to work after they got married. These weren’t women with constraints. They were talented and highly educated. They didn’t fit the conservative stereotype in which the in-laws forced them to resign from jobs to become homemakers. What’s more, they had supportive husbands and were not planning to have babies anytime soon. “Even so, if their husbands could support them financially, they chose to stop working,” says Keshavan. “This leads me to believe that women are wired to be homemakers, perhaps because of centuries of social conditioning that is now embedded in their psyche.” 

The fact that Keshavan believes this is particularly damning because her career is testimony to the fact that women aren’t “wired” this way. She founded Ray+Keshavan, ran it successfully and sold it to global brand company The Brand Union. Perhaps she is an anomaly. Or perhaps early financial exigencies forced her to work. So what’s the way forward? I ask her. What do we tell our daughters if we want them to be strong, successful career women? “Tell them to marry a poor man,” she says with a laugh, voicing exactly what I have been thinking.

After 50 years of feminism, it has come to this. Or has it? Are women the resilient gung-ho crusaders who have broken glass ceilings? Or are we escapist homemakers (and I do say this pejoratively in this context) who don’t have the courage to pursue our convictions—or our careers?

Human resources adviser and Mint columnist Hema Ravichandar disagrees with this analysis. “There are two types of women—those that take a job to find a life partner; and those who take a job to make a career of it,” she says. “Sujata’s take might hold true for the former but not for the latter. Of course, even those women who are not quitters may fall into the Mommy trap, or the transfer trap, or the H-4 visa trap, where they cannot work and have to compromise.”

I was raised by a mother who believed that women ought to be like “creepers” that hold the family tree together. I came of age at Mount Holyoke College, Massachusetts, where strong successful women taught me the trenchant politics of feminism. I am married to a man who believes that nurture can trump nature; that women can trump the “wiring” that may cause them to be like creepers or homemakers. My personal belief is that we women have a fear—not of failure but of success. We are afraid to reach for the stars because we are worried about what it will cost us— and our families. We are biologically and psychologically more invested in our children. So we don’t reach; we don’t push forward because we are already calculating the costs, before we need to. When the going gets tough, we compromise and pull back.

Bharati Jacob, founder-partner of venture capital firm Seedfund, sees something similar in women entrepreneurs. “I often see women start businesses and the moment it starts to scale, and they think they need outside money, they rope in their husbands. Why don’t they have the confidence to do it on their own?” she asks. Put another way, why is Robert Vadra (Priyanka’s husband) involved in her campaign?

Biological anthropologist Helen Fisher, who authored The First Sex: The Natural Talents of WomenAnd How They are Changing the World, disagrees that women entrepreneurs cop out. Rather, she says, “Tomorrow belongs to women.” Women’s natural talents: networking, people skills, connecting, nurturing and “web-thinking” are more suited to this information age. Women will start businesses, she says, and get ahead in the fields of medicine, education and philanthropy. With fascinating anecdotes and hard science, Fisher links the part of the brain that will help women fly—quite literally (Fisher is an identical twin, and her twin sister is a hot-air balloon pilot).

That said, even Fisher admits that women will not break into the top levels because they are more willing to strive for work-life balance. That doesn’t matter, she says. There will be a few men at the top, a tonne of women in the middle, and a lot of men at the bottom—construction workers “too drunk to zip up their pants”, as she says.

What women need are role models who shifted the paradigm; who played the game, not by men’s rules but by their own. Sarojini Naidu stands out as a shining example of this paradigm shift. She wasn’t born to dynastic power. Yet, she navigated her way through the male-dominated Congress party and held her own with style and substance.

Priyanka seems like a woman who is trying hard to strike this masculine-feminine balance. Should she decide to take the plunge into full-time politics, she has a role model in her mother. Should she choose to ignore the salacious Jawaharlal Nehru-Padmaja Naidu link, she might also be well-served by studying the style of this “Nightingale of India”, and imbuing it with a charisma that is all her own.

Shoba Narayan is neither creeper nor career woman. Like all women, she tries to be both, and therein, perhaps, lies the problem.

Write to her at thegoodlife@livemint.com