What are her greatest fears and concerns? What are her most important goals? What exchanges is she willing to make, and what exchanges is she not willing to make?

People seem to have two different selves: the experiencing self endures every moment of experience equally, while the remembering self puts almost all the weight of judgment on two moments afterwards, the worst moment and the last moment.

For humans, life is meaningful because it is a story. A story has a sense of wholeness, and its arc depends on those meaningful moments, those moments when something important happens. Evaluating people's levels of pleasure and pain moment by moment ignores this fundamental aspect of human existence. A life that appears happy on the surface may be empty, and a life that appears difficult may be dedicated to a great cause.

Palliative surgery. This surgery, regardless of its inherent destructiveness and risks, the overriding priority was to only take steps that were likely to make her feel immediately comfortable.

Our most brutal failure in treating the sick and elderly is failing to recognize that they have priorities other than safety and longevity; that the opportunity to construct a personal story is fundamental to sustaining meaning in life; In this way, we have the opportunity to reshape our aged care institutions, our culture, and our conversations.

The goal of hospice services, at least in theory, is to give people the best possible time, even if that best is what they define.

Seriously ill patients have other priorities besides simply prolonging their lives. The survey found that their main concerns included avoiding pain, strengthening connections with family and friends, being conscious, not being a burden to others, and achieving a sense of wholeness in their lives. Our technical health care system is completely inadequate to meet these needs, and the cost of this mistake is far more than can be measured in dollars. The question, therefore, is not how we can afford this system, but how we can build a system that helps people realize their most important aspirations at the end of their lives.

In the past, when death was more sudden, we didn't have to think about it. Today, rapid, catastrophic illness is the exception.

Over the past few decades, medical science has made centuries of experience, tradition, and language about death obsolete and created a new difficulty for humans: how to die.

The difference between standard medical care and hospice care is not a difference between treatment and inaction, but a difference in priorities. The goal of general medical care is to prolong life. To have a chance at future time, right now, we have to sacrifice your quality of life - through surgery, chemotherapy, and sending you to the intensive care unit.

Hospice, on the other hand, allows nurses, doctors, chaplains, and social workers to help people with life-threatening illnesses live the fullest possible lives in the here and now—much like the way nursing home reformers deployed staff to help the severely disabled. In the case of a terminal illness, that means focusing on relieving pain and discomfort, or trying to stay sane, or occasionally being able to go out with family—rather than focusing on the length of Cox's life.

Hospice services attempt to provide a new paradigm in how to die. While not everyone accepts its claims, those who do are demonstrating an art of death for our times. Doing so represents a fight—not just against pain, but against the seemingly unstoppable momentum of medical treatment.

You would think that doctors would be well prepared to handle difficult situations here, but at least two issues stand in the way. First, our own perspectives may be unrealistic.

Second, we often avoid even saying these estimates. The study found that while doctors generally tell patients when a cancer is untreatable, most are reluctant to make a specific prediction even when pressed.

“I think it is too popular to equate accepting death with having inner dignity,” he wrote in a 1985 article. “Of course, I agree with the biblical book of Ecclesiastes when it says, ‘In life, There is a time to die' - when I live to the end, I hope To be able to face the end of my life with equanimity, and in a way of my own choosing. Mostly, however, I prefer the more combative view that death is the ultimate enemy - and I feel that those who are against the light. He who extinguishes his anger has nothing to blame.”

When we cannot accurately know how much time is left, when we imagine that we have much more time than we have now, every impulse we have is to fight, so when we die, there will be chemotherapy left in our veins. Medications, a tube in his throat, and new stitches in his flesh.

●If your heart stopped, would you like CPR?

●Are you willing to take aggressive treatments such as intubation and mechanical ventilation?

●Are you willing to use antibiotics?

●If you cannot eat on your own, are you willing to take nasogastric feeding or intravenous nutrition?

Most doctors believe that the main purpose of discussing a terminal illness is to decide what the patient wants—whether he wants chemotherapy, whether he wants cardiac resuscitation, whether he wants hospice services. We focus on presenting facts and options. But, Bullock said, that's wrong.

“The main thing is to help people cope with all kinds of anxieties that are coming their way – anxiety about death, anxiety about pain, anxiety about loved ones, anxiety about money,” she explains. “People have a lot of worries and Real fear. “One conversation can’t cover it all. Accepting one's own mortality and gaining a clear understanding of medicine's limitations and possibilities is a process, not an epiphany.

Bullock lists the questions she likes to ask patients before they make a decision: What do they think the prognosis will be? What worries do they have about the future? What trade-offs are they willing to make? If their health deteriorates, how do they want to use their remaining time? If they can't make the decision themselves, who do they want to make the decision?

"Paternalistic" - We are medical authorities whose purpose is to ensure that the patient receives what we believe is the best treatment for him.

“Informative” – we tell the patient the facts and figures, and let the patient decide everything else.

“Explanatory” (shared decision-making model) – In this relationship, the doctor’s role is to help the patient determine what they want.

At some point, doctors need to help patients weigh their larger goals, even question them, and get them to rethink their ill-conceived priorities and beliefs. Not only is this the right approach, it's necessary.

What people seek first is the meaning behind the information, not the information itself. The best way to convey meaning, he said, is to tell people what the message means to you.

“Hospice is palliative care, providing care that helps patients deal with these difficulties,” she said. She went through the services that Medicare would pay for my father. He will have a palliative care doctor to help him adjust medications and other treatments to reduce his vomiting, pain and other symptoms as much as possible; he will have home visits from nurses and 24 hours a day emergency telephone nursing support. He has 14 hours a week of home health aide services, including help with bathing, dressing, cleaning the house — any non-medical tasks. There is also a social worker and spiritual counselor available for him. He will get the medical equipment he needs and can "cancel" (stop hospice services) at any time.

"Live your best today instead of sacrificing the present for the future."

The key word in her mind is "home". Home is the only place that dominates your priorities. At home, you can decide how to organize your time, how to share space, and how to take care of your belongings.

Karen Brown Wilson wanted to create a place for people like Lou Sanders to live freely and autonomously, no matter how poor their physical condition.

In 1983, a new "assisted living center" designed for seniors called Park Place opened in Portland.

The goal of "assisted living" is that no one has to feel institutionalized.

At the heart of Wilson's work is an attempt to solve a seemingly simple puzzle: What makes life worth living when we are old, frail, and unable to care for ourselves?

People do not become unhappy at all, but rather become happier as they age. They are less anxious, depressed, and angry than when they were younger.

Life is a skill. The peace and wisdom of old age are achieved over the course of time.

Wilson said a colleague once told her: "We want autonomy for ourselves, but we want safety for the people we love."

Without people like my grandfather to fall back on, our seniors live a controlled, supervised, institutionalized life. It was medicine's solution to an incurable problem, a life that was safe but devoid of the content they cared about.

He gradually realized that the missing element of this sanatorium was life itself, and he decided to try to inject some vitality into it.

his past behavior

Thomas explained the thinking behind his proposal. The goal, he said, is to combat what he calls the three plagues of nursing homes: boredom, loneliness and helplessness. To conquer these three plagues, the sanatorium needs some life. They're putting plants in every room; they're pulling out lawns to create vegetable gardens and flower gardens; they're bringing in animals.

In response to boredom, organisms will show spontaneity; in response to loneliness, organisms can provide companionship; in response to feelings of helplessness, organisms will provide opportunities to take care of other lives.

It is easier to measure how much people have become less dependent on drugs and how much longer they live, but it is much harder to measure the sense of value people get from their lives.

Royce wanted to understand: Why is it that mere existence, merely living with shelter, food, and safety, is empty and meaningless to us? What else do we need to feel that life is valuable?

The answer, he thinks, is: we all seek a reason beyond ourselves. To him, this is an intrinsic human need. The reason can be big (family, country, principles) or small (a construction project, taking care of a pet). What’s important is that in giving value to this cause, seeing it as something worth dying for, we give meaning to our lives.

The only way to make death not meaningless is to see yourself as part of something larger: family, community, society.

The problem with medicine and the institutions it creates to care for the sick and the elderly is not that they have a wrong idea of ​​what makes life meaningful, but that they have no idea at all. Medicine has a narrow focus. Medical professionals focus on repairing health, not nourishing the soul.

Bill Thomas wants to rebuild nursing homes, and Karen Wilson wants to eliminate them entirely and replace them with assisted living facilities. But they pursue the same idea: to help independent people maintain the value of their existence.

Making life meaningful in old age is a new way of thinking. So it takes more imagination and creativity than just making the elderly safe.

What is autonomy?

We are finally entering an era in which more and more people realize that their job is not to limit people's choices in the name of safety, but to expand them in the name of living a worthwhile life.

If you are unable to go to the toilet, eat, dress, bathe, have plastic surgery, get out of bed, leave your seat, or walk without the help of others (the so-called "eight major activities of daily living"), then it means that you lack basic self-care abilities.

If you can't shop, cook, clean your house, do your laundry, take your medications, make phone calls, travel alone, and handle your finances (the so-called "eight independent activities of daily living"), then you lack the ability to live safely on your own.

In contemporary society, the elderly and sick have gradually evolved from being supported by several generations to being supported by individuals alone, or assisted by medical and elderly care institutions. How does this happen? How do we move from Staram Gawande's life to Alice Hobson's?

The development trajectory of history is very clear: once people have enough resources and opportunities to say goodbye to their traditional way of life, they will embrace the new life without hesitation.

Rather than losing traditional status and control, the elderly share new status and control. Modernization has not reduced the status of the elderly, but only that of the family.

The story of aging in life is the story of the failure of the body’s organs.

The causes of aging are a hotly debated topic. The classic view is that aging is the result of random loss, while the latest view is that aging is orderly and genetically programmed.

"There is no single, universal mechanism for the aging process." - Felix Silverstone.

Every year, 350,000 Americans suffer a hip fracture due to falls. 40% of them end up in a nursing home, and 20% never walk again.

A doctor's job is to maintain the patient's quality of life. ——Chief geriatrician Jürgen Brudau.

How much professional geriatric care can improve people's lives - Chad Bolt, geriatrician and principal investigator of the University of Minnesota study.

Geriatrics: It asks each of us to think about the incurable conditions in our lives—the inevitable aging we will face—in order to make the small changes necessary to reshape aging

At a time when the illusion of immortality is prevalent, geriatricians are asking us to acknowledge our own aging, which is an unfortunate move.

As a geriatrician, he strives to objectively document the changes he experiences. He found that his skin was dry, his sense of smell had deteriorated, his night vision was getting worse, he tired easily, and he was losing teeth.

What concerned him most was changes in the mind. “I don’t think as clearly as I used to,” he said. “I used to be able to read the New York Times in half an hour. Now it takes me an hour and a half.”

Bolt thinks we have time to adopt another strategy: He directs geriatricians to train all primary care doctors and nurses to care for the elderly, rather than providing care themselves. But even this is a tall order—97 percent of medical students do not take geriatrics courses, and the strategy requires the state to pay geriatricians to teach how to care for patients rather than provide care themselves.

"We get in each other's way," Felix said.

"I feel like I'm missing a part of my body, like I've been dismembered," he told me. His voice was hoarse and his eyes were red as he spoke. What he found particularly comforting, however, was this: She didn't suffer. During her final weeks, she lived peacefully at home, enjoying the warmth of their long love, rather than living in a nursing home as a lost, confused patient.

A 1912 report from the Illinois Commission on Charities described one county almshouse: "It would be unseemly to house rats."

Over the course of Alice's life, older people in the industrialized world were able to escape the threat of this fate. Economic prosperity allowed even the poor to count on admission to nursing homes that provided three meals a day, professional health services, physiotherapy and bingo games, and they relieved the sufferings of frailty and old age for millions of people. Proper care and security became the norm to an extent that the "inmates" of the workhouse could not have imagined. However, most people still feel that as a place to spend the last part of their lives, nursing homes are scary, lonely and abominable. We need, we want more.

In the United States, in the years after the Social Security Act was passed in 1935, the number of elderly people in workhouses remained high. States moved to close workhouses, but found they could not be closed.

Nursing homes were never created to help people face the dependency problems of old age, but to free up hospital beds.

Over time, regulations tightened, health and safety issues finally came to the table, and nursing homes were no longer fire-prone buildings. But the core problem remains – the places where half of us will spend more than a year of our lives were never really built for us.