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Keep Your Voice, Even at the End of Life

PERSONAL HEALTH

Keep Your Voice, Even at the End of Life

By JANE E. BRODY

Published: January 17, 2011

The specter of “death panels” was raised yet again this month, prompting the Obama administration to give in to political pressure a second time in its effort to encourage end-of-life planning.

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Of course, the goal of this effort was not to make it easier to “pull the plug on grandma” in order to save the government’s money, as some opponents would have it. The regulation in question, which was withdrawn just days after it took effect on Jan. 1, simply listed “advance care planning” as one of the services that could be offered in the “annual wellness visit” for Medicare beneficiaries.

The widespread misconceptions about the regulation were exemplified in a letter to the editor published Dec. 29 in The New York Times. “Death panels,” the writer said, would have denied her 93-year-old mother colon cancer surgery that has given her the chance to live “several more years.”

But that is not at all what the regulation would have done. Instead, “by providing Medicare coverage for end-of-life planning with a physician, it would have encouraged doctors to talk to their patients about their wishes and made it far easier and more likely for these important conversations to take place,” said Barbara Coombs Lee, president of Compassion & Choices, an organization that helps people negotiate end-of-life problems.

With payment schedules that limit doctor visits to a mere 15 minutes or so, it is unreasonable to expect physicians to spend 30 or more unreimbursed minutes discussing with patients the many decisions that can arise at the end of life.

Encouraging such conversations might indeed save money in the long run. Doctors andhospitals are paid only for treating living patients, so there is always a possibility that financial incentives, conscious or unconscious, would prompt many expensive if futile life-extending measures — efforts that many patients would veto if they could.

In a study of patients with advanced cancer published in March 2009 in Archives of Internal Medicine, the costs of care during the last week of life were 55 percent higher among those who did not have end-of-life discussions with their doctors.

At least as important, the quality of life in their final days was much worse than among those who did have such discussions. Countless studies have shown that extensive medical interventions can make the last weeks of life an excruciating experience for patients and those who care about them.

An Individual Decision

Although talk about end-of-life options has often emphasized avoiding unwanted, intrusive and futile care, that does not mean everyone would or should make that choice. Many patients, especially younger ones, might be inclined to ask that every conceivable measure be taken.

Dr. Josh Steinberg, a primary care physician in Johnson City, N.Y., routinely discusses end-of-life desires with very ill patients. He told me about an AIDS patient who was down to 77 pounds and had no strength, no appetite and failing kidneys. But the man refusedhospice care, saying he wanted to go home and live as well as possible for as long as possible.

“Though we didn’t think he’d last more than a day or two, we got lucky,” Dr. Steinberg said. “We stumbled on a new treatment, he rallied, and he’s home doing well right now.”

For other patients, hospice care is the right decision. Studies have found that terminally ill patients are likely to live longer, with a better quality of life, when they choose hospice over aggressive treatment to the bitter end.

The point is that end-of-life care is an individual decision that should be thoroughly discussed with one’s family and physicians. Studies have shown that when doctors don’t know a patient’s wishes, they are inclined to use every possible procedure and medication to try to postpone the inevitable. More often than not, this shortens patients’ lives and prolongs bereavement for the survivors.

In an interview on the syndicated news program “Democracy Now!” on Jan. 5, the writer and surgeon Dr. Atul Gawande said that patients with terminal cancer who discuss end-of-life choices with their doctors “are less likely to die in the intensive care unit, more likely to have a better quality of life and less suffering at the end, do not have a shorter length of life, and six months later their family members are markedly less likely to be depressed.”

Plan While You Still Can

For many more of us these days, the end does not come swiftly via a heart attack or fatal accident, but rather after weeks, months or years battling a chronic illness like cancer,congestive heart failure, emphysema or Alzheimer’s disease. When doctors do not know how you’d want to be treated if your heart stopped, or you were unable to breathe or eat and could not speak for yourself, they are likely (some would say obliged) to do everything in their power to try to keep you alive.

A year ago, my husband was given a diagnosis of Stage 4 cancer. As his designated health care proxy, I had agreed long before he became ill to abide by the instructions in his living will. If he was terminally ill and could not speak for himself, he wanted no extraordinary measures taken to try to keep him alive longer than nature intended.

Knowing this helped me and my family avoid agonizing decisions and discord. We were able to say meaningful goodbyes and spare him unnecessary physical and emotional distress in his final weeks of life.

Preparing these advance directives should not wait until someone develops a potentially fatal disease. Patients in the throes of terminal illness may resist discussions suggesting that death may be imminent, and close family members may be reluctant to imply as much.

Indeed, judging from national studies and people I know (including a 90-year-old aunt), most Americans regardless of age seem reluctant to contemplate the certainty that one day their lives will end, let alone discuss how they’d want to be treated when the end is near.

A study published in January 2009 in The Journal of the American Geriatric Societyshowed that 40 percent of people questioned had not yet thought about advanced-care planning and 90 percent hadn’t documented their wishes for end-of-life care.

Ideally, everybody over 18 should execute a living will and select a health care proxy — someone to represent you in medical matters.

Compassion & Choices has an excellent free guide and “tool kit” to help people prepare advanced directives. They can be downloaded from the organization’s Web site,www.compassionandchoices.org (select the “care” tab, then “planning for the future”) or call (800) 247-7421 for a free hard copy of the documents.

A version of this article appeared in print on January 18, 2011, on page D7 of the New York edition.

Aging: Mediterranean Diet as Brain Food

VITAL SIGNS

Aging: Mediterranean Diet as Brain Food

By NICHOLAS BAKALAR

Published: January 13, 2011

REPRINTS

The Mediterranean diet — heavy on vegetables, fish and olive oil, with moderate amounts of wine — may be associated with slower rates of mental decline in the elderly.

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Some previous studies have suggested that the diet has beneficial effects for the brain, but the evidence has not been strong. A new report analyzed data from a continuing study of 3,790 Chicago residents 65 and older that began in 1993. The researchers tested the subjects’ mental acuity at three-year intervals, and tracked their degree of adherence to the Mediterranean diet on a 55-point scale.

High scores for adherence to the diet were associated with slower rates of cognitive decline, even after controlling for smoking, education, obesity, hypertension and other factors.

The lead author, Christine C. Tangney, an associate professor of nutrition at Rush Medical College in Chicago, said sticking to the diet made a large difference. Those in the top third for adherence, she said in a telephone interview, were cognitively the equivalent of two years younger than those in the bottom third.

The study, published in The American Journal of Clinical Nutrition, has significant strengths in its prospective design, large sample and use of a well-validated dietary questionnaire. But the authors acknowledged that they could not account for all possible variables, and cautioned that it was an observational study that draws no conclusions about cause and effect.

A version of this article appeared in print on January 18, 2011, on page D6 of the New York edition.

The Claim: Eating Ginger Helps Reduce Muscle Pain and Soreness

REALLY?

The Claim: Eating Ginger Helps Reduce Muscle Pain and Soreness

By ANAHAD O’CONNOR

Published: January 17, 2011

REPRINTS

THE FACTS

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Ginger’s ability to calm an upset stomach is well known. But more recently, scientists have wondered whether its soothing effects might extend to sore muscles.

Ginger, a member of the same plant family as turmeric, contains anti-inflammatory compounds and volatile oils — gingerols — that show analgesic and sedative effects in animal studies. So last year a team of researchers looked at whether ginger might do the same in humans.

In the study, published in The Journal of Pain in September, the scientists recruited 74 adults and had them do exercises meant to induce muscle pain and inflammation. Over 11 days, the subjects ate either two grams of ginger a day or a placebo. Ultimately, the ginger groups experienced roughly 25 percent reductions inexercise-induced muscle pain 24 hours after a workout.

In a similar double-blind study, scientists compared what happened when subjects consumed either two grams of ginger or a placebo one day and then two days after exercise. The ginger appeared to have no effect shortly after ingestion. But it was associated with less soreness the following day, leading the researchers to conclude that ginger may help “attenuate the day-to-day progression of muscle pain.”

Other studies have shown that consuming ginger before exercise has no impact on muscle pain, oxygen consumption and other physiological variables during or immediately after a workout, suggesting that if ginger does have any benefits, they may be limited to reductions in soreness in the days after a workout.

THE BOTTOM LINE

Ginger may help ease pain and soreness, but only a day or more after a workout.

ANAHAD O’CONNOR scitimes@nytimes.com

A version of this article appeared in print on January 18, 2011, on page D5 of the New York edition.

When Self-Knowledge Is Only the Beginning

MIND

When Self-Knowledge Is Only the Beginning

By RICHARD A. FRIEDMAN, M.D.

Published: January 17, 2011

REPRINTS

It is practically an article of faith among many therapists that self-understanding is a prerequisite for a happy life. Insight, the thinking goes, will free you from your psychological hang-ups and promote well-being.

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Perhaps, but recent experience makes me wonder whether insight is all it’s cracked up to be.

Not long ago, I saw a young man in his early 30s who was sad and anxious after being dumped by his girlfriend for the second time in three years. It was clear that his symptoms were a reaction to the loss of a relationship and that he was not clinically depressed.

“I’ve been over this many times in therapy,” he said. He had trouble tolerating any separation from his girlfriends. Whether they were gone for a weekend or he was traveling for work, the result was always the same: a painful state of dysphoria and anxiety.

He could even trace this feeling back to a separation from his mother, who had been hospitalized for several months for cancer treatment when he was 4. In short, he had gained plenty of insight in therapy into the nature and origin of his anxiety, but he felt no better.

What therapy had given this young man was a coherent narrative of his life; it had demystified his feelings, but had done little to change them.

Was this because his self-knowledge was flawed or incomplete? Or is insight itself, no matter how deep, of limited value?

Psychoanalysts and other therapists have argued for years about this question, which gets to the heart of how therapy works (when it does) to relieve psychological distress.

Theoretical debates have not settled the question, but one interesting clue about the possible relevance of insight comes from comparative studies of different types of psychotherapy — only some of which emphasize insight.

In fact, when two different types of psychotherapies have been directly compared — and there are more than 100 such studies — it has often been hard to find any differencesbetween them.

Researchers aptly call this phenomenon the Dodo effect, referring to the Dodo bird inLewis Carroll’s “Alice in Wonderland” who, having presided over a most whimsical race, pronounces everyone a winner.

The meaning for patients is clear. If you’re depressed, for example, you are likely to feel better whether your therapist uses a cognitive-behavioral approach, which aims to correct distorted thoughts and feelings, or an insight-oriented psychodynamic therapy.

Since the common ingredient in all therapies is not insight, but a nonspecific human bond with your therapist, it seems fair to say that insight is neither necessary nor sufficient to feeling better.

Not just that, but sometimes it seems that insight even adds to a person’s misery.

I recall one patient who was chronically depressed and dissatisfied. “Life is just a drag,” he told me and then went on to catalog a list of very real social and economic ills.

Of course, he was dead-on about the parlous state of the economy, even though he was affluent and not directly threatened by it. He was a very successful financial analyst, but was bored with his work, which he viewed as mechanical and personally unfulfilling.

He had been in therapy for years before I saw him and had come to the realization that he had chosen his profession to please his critical and demanding father rather than follow his passion for art. Although he was insightful about much of his behavior, he was clearly no happier for it.

When he became depressed, though, this insight added to his pain as he berated himself for failing to stand up to his father and follow his own path.

Researchers have known for years that depressed people have a selective recall bias for unhappy events in their lives; it is not that they are fabricating negative stories so much asforgetting the good ones. In that sense, their negative views and perceptions can be depressingly accurate, albeit slanted and incomplete. A lot of good their insight does them!

It even makes you wonder whether a little self-delusion is necessary for happiness.

None of this is to say that insight is without value. Far from it. If you don’t want to be a captive of your psychological conflicts, insight can be a powerful tool to loosen their grip. You’ll probably feel less emotional pain, but that’s different from happiness.

Speaking of which, my chronically depressed patient came to see me recently looking exceedingly happy. He had quit his job and taken a far less lucrative one in the art world. We got to talking about why he was feeling so good. “Simple,” he said, “I’m doing what I like.”

I realized then that I am pretty good at treating clinical misery with drugs and therapy, but that bringing about happiness is a stretch. Perhaps happiness is a bit like self-esteem: You have to work for both. So far as I know, you can’t get an infusion of either one from a therapist.

Dr. Richard A. Friedman is a professor of psychiatry at Weill Cornell Medical College in Manhattan.

A version of this article appeared in print on January 18, 2011, on page D5 of the New York edition.

Close Look at Orthotics Raises a Welter of Doubts

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By GINA KOLATA

Published: January 17, 2011

REPRINTS

Benno M. Nigg has become a leading researcher on orthotics — those shoe inserts that many athletes use to try to prevent injuries. And what he has found is not very reassuring.

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For more than 30 years Dr. Nigg, a professor of biomechanics and co-director of the Human Performance Lab at the University of Calgary in Alberta, has asked how orthotics affect motion, stress on joints and muscle activity.

Do they help or harm athletes who use them? And is the huge orthotics industry — from customized shoe inserts costing hundreds of dollars to over-the-counter ones sold at every drugstore — based on science or on wishful thinking?

His overall conclusion: Shoe inserts or orthotics may be helpful as a short-term solution, preventing injuries in some athletes. But it is not clear how to make inserts that work. The idea that they are supposed to correct mechanical-alignment problems does not hold up.

Joseph Hamill, who studies lower-limb biomechanics at the University of Massachusettsin Amherst, agrees.

“We have found many of the same results,” said Dr. Hamill, professor of kinesiology and the director of the university’s biomechanics laboratory. “I guess the main thing to note is that, as biomechanists, we really do not know how orthotics work.”

Orthotists say Dr. Nigg’s sweeping statement does not take into account the benefits their patients perceive.

The key measure of success, said Jeffrey P. Wensman, director of clinical and technical services at the Orthotics and Prosthetics Center at the University of Michigan, is that patients feel better.

“The vast majority of our patients are happier having them than not,” he said about orthotics that are inserted in shoes.

Seamus Kennedy, president and co-owner of Hersco Ortho Labs in New York, said there was an abundance of evidence — hundreds of published papers — that orthotics can treat and prevent “mechanically induced foot problems,” leading to common injuries like knee pain, shinsplints and pain along the bottom of the foot.

“Orthotics do work,” Mr. Kennedy said. “But choosing the right one requires a great deal of care.”

Yet Scott D. Cummings, president of the American Academy of Orthotists and Prosthetists, says the trade is only now moving toward becoming a science. So far, most of the focus in that direction has been on rigorously assessing orthotics and prosthetics for other conditions, like scoliosis, with less work on shoe orthotics for otherwise healthy athletes.

“Anecdotally, we know what designs work and what designs don’t work” for foot orthotics, said Mr. Cummings, who is an orthotist and prosthetist at Next Step in Manchester, N.H. But when it comes to science and rigorous studies, he added, “comparatively, there isn’t a whole lot of evidence out there.”

Dr. Nigg would agree.

In his studies, he found there was no way to predict the effect of a given orthotic. Consider, for example, an insert that pushes the foot away from a pronated position, or rotated excessively outward. You might think it would have the same effect on everyone who pronates, but it does not.

One person might respond by increasing the stress on the outside of the foot, another on the inside. Another might not respond at all, unconsciously correcting the orthotic’s correction.

“That’s the first problem we have,” Dr. Nigg said. “If you do something to a shoe, different people will react differently.”

The next problem is that there may be little agreement among orthotics makers about what sort of insert to prescribe.

In one study discussed in his new book, “Biomechanics of Sport Shoes,” Dr. Nigg sent a talented distance runner to five certified orthotics makers. Each made a different type of insert to “correct” his pronation.

The athlete wore each set of orthotics for three days and then ran 10 kilometers, about 6 miles. He liked two of the orthotics and ran faster with them than with the other three. But the construction of the two he liked was completely different.

Then what, Dr. Nigg asked in series of studies, do orthotics actually do?

They turn out to have little effect on kinematics — the actual movement of the skeleton during a run. But they can have large effects on muscles and joints, often making muscles work as much as 50 percent harder for the same movement and increasing stress on joints by a similar amount.

As for “corrective” orthotics, he says, they do not correct so much as lead to a reduction in muscle strength.

In one recent review of published papers, Dr. Nigg and his colleagues analyzed studies on orthotics and injury prevention. Nearly all published studies, they report, lacked scientific rigor. For example, they did not include groups that, for comparison, did not receive orthotics. Or they discounted people who dropped out of the study, even though dropouts are often those who are not benefiting from a treatment.

Being generous about studies with design flaws that could overstate effects, Dr. Nigg and his colleagues concluded that custom-made orthotics could help prevent and treat plantar fasciitis, a common injury to a tendon at the bottom of the foot, and stress fractures of the tibia, along the shin. They added, though, that the research was inadequate for them to have confidence in those conclusions.

Dr. Nigg also did his own study with 240 Canadian soldiers. Half of them got inserts and the others, for comparison, did not.

Those who got inserts had a choice of six different types that did different things to foot positioning. Each man chose the insert he found most comfortable and wore it for four months. The men selected five of the six inserts with equal frequency.

The findings were somewhat puzzling: While the group that used inserts had about half as many injuries — defined as pain that kept them from exercising for at least half a day — there was no obvious relation between the insert a soldier chose and his biomechanics without it.

That’s why Dr. Nigg says for now it is difficult to figure out which orthotic will help an individual. The only indication seems to be that a comfortable orthotic might be better than none at all, at least for the activities of people in the military.

So where does this leave people like Jason Stallman, my friend and colleague at The New York Times? Jason has perfectly flat feet — no arch. He got his first pair of orthotics at 12 or 13 and has worn orthotics all the time, for walking and running ever since. About a year ago he decided to try going without them in his everyday life; he still wears them when he runs.

Every medical specialist Jason has seen tried to correct his flat feet, but with little agreement on how to do it.

Every new podiatrist or orthopedist, he told me, would invariably look at his orthotics and say: “Oh, these aren’t any good. The lab I use makes much better ones. Your injury is probably linked to these poor-fitting orthotics.”

So he tried different orthotic styles, different materials, different orthotics labs with every new doctor.

That is a typical story, Dr. Nigg says. In fact, he adds, there is no need to “correct” a flat foot. All Jason needs to do is strengthen his foot and ankle muscles and then try running without orthotics.

Dr. Nigg says he always wondered what was wrong with having flat feet. Arches, he explains, are an evolutionary remnant, needed by primates that gripped trees with their feet.

“Since we don’t do that anymore, we don’t really need an arch,” he wrote in an e-mail. “Why would we? For landing — no need. For the stance phase — no need. For the takeoff phase — no need. Thus a flat foot is not something that is bad per se.”

So why shouldn’t Jason — or anyone, for that matter — just go to a store and buy whatever shoe feels good, without worrying about “correcting” a perceived biomechanical defect?

“That is exactly what you should do,” Dr. Nigg replied.