By Dennis McCullough and Jacqueline C. Wootton
Originally published on November 2008: Dennis McCullough 2008
This mild-mannered, gentle book belies a steely and radical approach to medicine. On the one hand, it is a consumer book full of practical advice and wisdom on the best way to care for aging parents in their final stages of life. As a geriatrician, Dennis McCullough has spent over 30 years developing a practice that combines conventional medicine with a holistic approach, including alternative therapies where appropriate, and emphasizing quality of life for the patient and entire family. In outlining 8 stages of later life (Stability, Compromise, Crisis, Recovery, Decline, Prelude to Dying, Death, and Grieving/Legacy), McCullough weaves in the story of his own mother’s decline from healthy 85- year-old to frail 92-year-old dying in a hospice surrounded by family.
On the other hand, with an increasing proportion of the population living longer, this book is a serious critique of current medical establishment practice of geriatrics, and the principles developed could well be applied to medicine generally and not just to geriatric care. The author does not cast blame but draws out the structural problems of current guidelines. The details apply mainly to the United States, but the core values pervade all Western health care systems. His subtle indictment is scattered throughout the book. The combined punch is staggeringly tough.
Hospital-based modern medicine with the emphasis on high-tech diagnostics, formulaic procedures, and standard drug medications is designed for saving lives and restoring function in younger patients; these measures are often pointless for the very elderly if there is no gain in quality of life. For example, a simple manual breast examination is not only gentler but more appropriate than an annual mammogram for the over-80s. Sometimes a hip or knee replacement operation may not be a wise choice if the patient is unlikely to recover well or is unable to withstand the demanding regimen of months of physiotherapy and rehabilitation.
Many older people would rather die in their own homes or close to family and not in hospital hooked up to lifesaving machinery. Yet the usual response to a medical crisis involves a rush to the emergency room where a busy doctor will order insurance-covered drugs, tests, and procedures. Cutting-edge acute medical interventions are costly as well as unsuitable in many cases for the frail elderly; they neither meet their needs nor respect their wishes.
Although the precise statistics vary, most analysts show that health care expenditure at the end of life consumes a disproportionately large slice of a country’s health care budget. McCullough calls for higher-quality, lower-cost, considerate care that is sensitive and appropriate to the needs of the individual patient. It should not bankrupt entire families to find suitable solutions. Watchful anticipation, compassion, and common sense are required to pre-empt and avoid crises and select appropriate treatments.
There can be considerable advantages if family members accompany their parents on the doctor office visits to discuss the merits and disadvantages of continuing drugs, such as cholesterol or blood pressure lowering medications that were important around age 75 but of dubious benefit a decade or more later. Doctors, for their part, need to accept, or even welcome a greater degree of patient and caregiver discussion and sharing of decisions as end-of-life decisions have repercussions far beyond the individual, affecting the entire family and caregiver team. Finding the individually appropriate level of care requires time and team effort. Family- centered advocacy groups are key to McCullough’s concept of considerate elder care. Still, there is likely to be a thin line between patient empowerment and doctor alienation, and a more detailed model of how this might be developed would have been useful here.
Handling the medical bureaucracy is yet another challenge to those caring for an elderly relative. Accordingly, the author recommends that the family and care team request coordinated care to avoid the morass of “different professional jargon and terminology, different paperwork, different rules, different insurance codes, different providers, different ‘cultures’” (p. 68). Too bad not all doctors will be as receptive as Dr. McCullough. Attempting to coordinate and slow down fast doctors could end up as quite a bumpy ride.
Early detection of potential threats that may result in a medical crisis is vital to avoid putting the elder into the hospital, with all the secondary risks of infection and confusion. However, avoiding debilitating side-effects of over- medication is the other side of the equation. Growing old is a life stage and not an ailment. Relatively higher blood pressure, mild elevations of blood sugar, joint deterioration, and some decline of memory are part of the normal aging process, yet the elderly may be inappropriately labeled with medical diagnoses such as hypertension, diabetes, osteoarthritis, and Alzheimer’s disease. A balanced diet, the right level of exercise, good hygiene, and sustainable living habits are essential and the practice of gentle alternatives to conventional medications, such as t’ai chi or meditation, may be worth more than a cabinet full of drugs. Most alternative practitioners are trained to take time and listen, to touch and show compassion. Indeed, in Tibetan Medicine, a prerequisite for becoming a physician is to be a “good” person. Contrariwise, one backhanded criticism of alternative medicine is that it invokes the placebo effect and that healing is not due to the efficacy of the therapeutic method but to the time taken (as though taking time were bad medical practice).
Dennis McCullough calls his approach to elder care “slow medicine,” not a totally new concept but probably the most highly developed exposé to date. It is a direct parallel to the Italian-inspired “slow food” movement, which rejects the assembly line methods of agribusiness in favor of small-scale, sustainable agriculture that preserves local culinary traditions and high-quality foods. However, it is not, in the author’s words, “a nostalgic return to some imagined romantic past.” The idea and practice of “slow medicine” in elder care may open new paths to an evolved and appropriate integrative approach to medicine for all life’s stages, from cradle to grave.