Book Review – Reinventing Aging – Shirley Yoder Brubaker

We’ve started a series of book reviews – all about books on aging! This week, Barrie McMaster reviews a book on reinventing aging. Read the review here…

Book Review – Aging Matters; finding your calling for the rest of your life

We’ve started a series of book reviews – all about books on aging! This week, Barrie McMaster reviews Paul Steven’s book “Aging Matters”. Read the review here…

Is this the future for nursing homes?

Quality of life: A ‘dementia village’ in the Netherlands is changing the way we think about care and aging

Published in the Vancouver Sun, December 7th, 2014

Weesp is an idyllic Dutch town with narrow cobblestone streets, canals, windmills, stores selling wooden shoes, and cheese shops. But what has put Weesp on the map are not the tourist attractions, but a neighbourhood designed and built exclusively for people with advanced stages of dementia who can no longer live independently.

De Hogeweyk Dementia Village is designed around the concept of quality of life and has six to eight people living in a home each with their own bedroom and shared living room, dining room and bathing rooms.

In the morning, residents wake up at their own time and gather around the dining room table, choosing what they would like for breakfast. A popular choice is pancakes. During breakfast, the conversation often focuses on what activities the residents want to do for the rest of the day. Following breakfast, a resident goes shopping in the local supermarket for groceries to be used for lunch and dinner.

A freezer at the entrance of the grocery store has frozen ice cream treats to satisfy a sweet tooth. In the same store, personal items such as incontinence products, medical supplies and cleaning supplies are purchased for the homes.

Once the resident has purchased her items, she walks back to her residence with the aid of her shopping cart. The supermarket is located in The Passage, a two-storey marketplace complete with a café, restaurant and art studio.

The Rembrandt Art Studio welcomes residents who arrive at their own pace and schedule. In the art studio, seniors paint like the Dutch masters Van Gogh and Vermeer. The art studio offers its residents a warm beverage to help keep their attention. When the drink is finished and the art is complete, the residents make their way to another attraction allowing space for other residents to paint.

The marketplace is large enough to feel like a town square and is used for group activities on rainy days. A market stand sells fresh-cut flowers, a newsstand has the daily papers, and large canvases featuring abstract art decorate the empty spaces on the walls.

Leaving the Marketplace, Main Street has the look and feel of its namesake. The pedestrian walkway with cobblestones has a café, hardware store for repairing bikes, walkers and other mobility aids to independence.

A physiotherapist provides both individual restorative therapy and group fitness exercises classes. A doctor’s office is located on the main drag, as is a modern beauty salon. One store front is called Mozart Hall and is decorated in Louis XIV style with classy dining tables and chairs and chandeliers. The hall is used for music therapy where residents create their own musical entertainment, much like they would have before moving to the dementia village.

A theatre hosts performances by local musicians and entertainers who champ at the bit to add this venue to their resumé. Another storefront is an activities booking travel agent who arranges trips to Amsterdam, De Hague, Haarlem, Delft and other regional cities and cultural attractions.

The main restaurant is decorated like a hip spot with perfectly poured espresso coffees and delicious biscotti. The lunchtime buffet menu is available to residents and guests from the local town and is a popular local eatery. The food quality is the same or better than the finest local restaurants and is part of the vibrant local food scene. It is a cool place to go out for a meal, not just a place to have a meal with grandma.

The buildings have the look and feel like the neighbouring buildings of both apartments and industrial park. The sounds of children playing can be heard in the distance as a school is located across the street with a soccer pitch visible for the residents to watch.

The homes are designed around people from similar backgrounds to encourage new friendships, to decrease aggressive behaviours, and to increase the chance of people getting along based on speaking the same language from their similar life experience. Separate houses are designed for Indonesian residents, while others are from urban areas and another for people who spent their lives farming.

Each home has distinctive features that help residents identify their home. One doorfront has a pair of wooden shoes, a bird feeder, and a small planter box with tulips and a mailbox with a large number 5 indicating the address.

The homes have their own patio with sturdy tables and chairs, covered shelter and a garden, which have been beautifully maintained. Park benches line outdoor space that is interconnected to other gardens sharing a common pathway for outdoor activities like Bochi, gravel field, life-size chess set, and lots of places to sit and take a break to watch what others are doing and to enjoy the independence of the outdoors.

An elevator without buttons automatically transports residents to and from their residences equipped with a motion sensor and electronic door closure sensors.

Gone are all the characteristics of an institutional living environment. Long corridors have been replaced with pedestrian boulevards and wandering paths; there are no sterile looking shiny floors reflecting the fluorescent tube lighting above. Care aides dressed in hospital scrubs do not rush residents to a main dining room to make it to a meal on time.

As demographic trends advance, homes for the aged will transform the aging experience with new models of care, and innovative living environments dignifying the lives of people with severe memory impairments. Theses communities are based on the need for a global response to the looming Alzheimer’s disease crisis that will triple in the next 40 years. New ways of caring for seniors in purpose-built environments as well as new options for living at home longer will perhaps mean that tomorrow’s seniors may never need a traditional nursing home.

This is not just a business model. It is a different way of thinking about the way people with advanced dementia experience the aging journey.

The Dementia Village is operated by Vivium, which operates other sites in the area and previously tested many of the design elements and philosophies to living and approaches to caring that have given the site an international reputation as a leading place for how innovative dementia care changes perceptions of what is important to residents, staff and families.

The village is modelled after the open-minded societal values of The Netherlands. If you walk down streets of any village, past the tourist attractions, you will find all of the same elements of living a meaningful life that you find in the Dementia Village. What is unique is the avant garde philosophy that freedom equals happiness. The seniors in the village can come and go as they please. Everywhere is safe within De Hogeeweyk. No one can leave the community unnoticed. As most seniors with advanced dementia cannot independently enter society, why not invite society into their purpose built communities?

Dan Levitt is executive director of Tabor Village in Abbotsford and an adjunct professor in the Gerontology Department at Simon Fraser University.

Do away with ‘do not resuscitate’ – a doctor’s thoughts

Published in the National Post – December 1, 2014

National Post article – by Dr. Brett Belchetz, an emergency room physician

Belchetz: ‘Family members acting as powers of attorney often ask me, “how will I live with myself if I tell you to do nothing?” ’ CPR comes with serious risks, but patients are leery of choosing a natural death because of the way the medical profession handles end-of-life care

The 83-year-old man lay in front of me. Weak and pale, his blood pressure dropping, he was barely strong enough to lift his head off of his stretcher to speak to me. The patient — let’s call him Paul — had been brought to my emergency room by his family after several days of heavy gastrointestinal bleeding.

Paul had suffered from a heart attack two years prior, and I worried greatly about the strain his ongoing blood loss was causing his system. Talking to him and his family, I urgently outlined his treatment plan, finally asking the question I pose to every elderly or chronically ill patient: “Should your heart stop beating while under my care, would you like us to attempt CPR (cardiopulmonary resuscitation)?”

It is a question most physicians dread asking, as no matter how the issue is raised, patients and family members react at first with shock, aghast that this is even a question at all. Swayed by Hollywood’s depiction of cardiac arrests, where 75% of fictional resuscitation attempts are successful and uncomplicated, the initial answer for most patients as to whether to attempt CPR if their heart stops beating in a hospital is an automatic “yes.”

Unfortunately, in the real world, the statistics are far more grim, and the decision far more difficult. CPR performed on patients who are already in hospital carries a survival rate of approximately 15%, while CPR performed in nursing homes achieves only a 2% survival rate. Survival rates among those with serious illnesses such as cancer (6.7%) and dialysis (2%) are dismal.

Even worse, one study found that among CPR survivors, only 51% were able to be discharged, while the rest required permanent nursing home or hospice care. At the same time, over 50% of CPR survivors exhibit at least some degree of brain damage.

Unlike what is depicted in movies, the truth is that CPR is a brutal event. In my experience, chest compressions often break ribs, sometimes puncture lungs and occasionally even rupture abdominal organs. Those who survive CPR frequently spend lengthy periods of time in intensive care units (ICUs).

Due to these stark outcomes, physicians are obligated, when treating patients whose CPR outcomes are the most bleak, to clarify whether resuscitation in hospital is indeed what these patient and their loved ones want. I make it clear in these discussions that CPR is likely to fail, likely to be painful while it is being performed and, if successful, will carry a 50% chance of lifelong institutionalization and/or brain damage.

I ask patients what their goals and fears are for end of life: Do they wish for more days above all else, or do they fear pain and suffering and the risk of a prolonged loss of independence the most? When it is explained this way, a significant number of patients who initially prefer CPR, change their minds. For Paul, this was definitely the case.

Regrettably, however, the standard in health care throughout the world is to require patients or decision makers to sign what is called a “do not resuscitate” or DNR form, once this decision has been made. It is at this point that end-of-life discussions often become confused, complicated by feelings of remorse and guilt.

Family members acting as powers of attorney often ask me, “how will I live with myself if I tell you to do nothing?” Similarly, patients struggle with the negativity inherent in the DNR statement. One cancer patient I treated recently stated, “I don’t want to end up in an ICU, but I feel like I’m giving up when you use a term like DNR.”

To avoid such uncomfortable discussions, some physicians skip DNR consultations altogether. A 2012 study found that only 20% of elderly patients had actually created a document with their physician to record their CPR wishes.

In order to deal with the fact that most elderly and severely ill patients opt out of receiving CPR once the risks are explained to them, but are leery about signing DNR forms, we need to change our vocabulary. Instead of asking patients who say no to CPR to sign a form telling us not to care for them, physicians should be asking them to affirm their preference for a natural, dignified passing. Simply put, I believe the term DNR needs to go away, to be replaced with the term AND – Allow Natural Death.

Thus, I recently stopped using the words “do not resuscitate” in all such discussions. For legal purposes, I retain the term on forms, but underneath, I write AND, and ask patients to focus instead on those three letters when they consider what they are requesting.

In my admittedly unscientific sample with AND, my discussions with these patients have transformed from what was a morose part of my job, into something inspiring. I no longer witness the terrible guilt among family members that I so frequently saw when the choice to avoid CPR was defined solely by the term DNR.

Thankfully, Paul never did suffer a cardiac arrest that day. He responded well to treatment, and later he told me that the term AND optimistically captured his wish for dignity in death, while DNR made him feel like we saw him as unworthy of care. It is a sentiment that I can only hope the rest of my profession will hear and respond to, and that one day soon, all of us in the medical profession will collectively choose to do away with the words “do not resuscitate.”

Seniors Advocate – The Journey Begins

In March 2014, the BC government appointed Isobel Mackenzie as the Seniors Advocate. Ms. Mackenzie has a broad mandate to monitor and review system-wide issues affecting the well-being of seniors and raise awareness about resources available to them. The Advocate will also make recommendations to government and those who deliver seniors’ services related to health care, personal care, housing, transportation and income support.

We had the privilege of meeting Isobel Mackenzie at the BC Chapter of the Canadian College of Health Leaders. We were thrilled to hear that her background is administration in both home health and higher levels of care. She understands the issues from the inside.

In October, Isobel Mackenzie stated that “We Can Do Better” and released her first report, Together We Can Do Better. Click for PDF.

The Seniors Advocate is seeking seniors to participate in Seniors Councils throughout the province. Application deadline is December 4, 2014. Seniors Advocate Council of Advisers Website.