This page describes the organizational forces that limit change.
It explains how to overcome
them when necessary.
This page uses an example to illustrate how:
- A business can gain focus from targeting key customers,
- Business planning activities performed by the whole organization can build awareness, empowerment and coherence.
- A program approach can ensure strategic alignment.
This page uses the example of HP's printer organization freeing
itself from its organizational constraints to sell a printer
targeted at the IBM pc user.
The constraints are described.
The techniques to overcome them are implied.
The constraints are described.
The techniques to overcome them are implied.
Agent death
Summary
Gawande uses his personal experience, analytic skills and lots of stories of innovators to demonstrate better ways of coping with aging and death. He introduces the lack of focus on aging and death in traditional medicine. And goes on to show how technology has amplified this stress point. He illustrates the traditional possibility of the independent self, living fully while aging with the support of the extended family. Central planning responded to the technological and societal changes with poorly designed infrastructure and funding. But Gawande then contrasts the power of bottom up innovations created by experts responding to their own family situations and belief systems.Gawande then explores in depth the challenges that unfold currently as we age and become infirm. He notes that the world is following the US is the United States of America. path. As such it will have to understand the dilemma of integrating medical treatment and hospice strategies. He notes that all parties involved need courage to cope.
He proposes medicine must aim to assure well being. At that point all doctors will practice palliative care.
Complex adaptive system (CAS) models of agency, death, evolution, cooperation and adaptations in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage. Holland argues: complex adaptive systems (CAS) adapt due to the influence of schematic strings on agents. Evolution indicates fitness when an organism survives and reproduces. For his genetic algorithm, Holland separated the adaptive process into credit assignment and rule discovery. He assigned a strength to each of the rules (alternate hypothesis) used by his artificial agents, by credit assignment - each accepted message being paid for by the recipient, increasing the sender agent's rule's strength (implicit modeling) and reducing the recipient's. When an agent achieved an explicit goal they obtained a final reward. Rule discovery used the genetic algorithm to select strong rule schemas from a pair of agents to be included in the next generation, with crossing over and mutation applied, and the resulting schematic strategies used to replace weaker schemas. The crossing over genetic operator is unlikely to break up a short schematic sequence that provides a building block retained because of its 'fitness'; In Deacon's conception of evolution, an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary.
to new technologies are discussed.
Being Mortal
In Atul Gawande's book 'Being Mortal' he uses true stories to illustrate the various ways in which the old, frail and dying are cared for by the evolving societies in which they live. As a practicing surgeon he notes that his medical training ignored: how death unfolds, how people experience the end of their lives, how it affects them; the subject seemed beside the point when the goal was to save lives.It has been typical to treat a dying person as if they just need the right treatment and they will become fully functional again.
Gawande's initial simplistic view was that he should treat all his patients with honesty and kindness which would result in his providing compassionate indicates an emotional state where resonance with someone else's distress leads one to help them. The Dalai Lama stresses we must feel compassion for ourselves and others. Tara Brach sees compassion as our capacity to relate in a tender and sympathetic way to what we perceive. Meditation focused on feeling love for the suffering, strengthens compassion by activating the neuron networks for parental love for a child: ACC, insula, striatum, PAG, orbitofrontal cortex; and inducing a reduction in areas responsible for negative emotions.
care. But some of his surgical patients were forced to confront the realities of decline and mortality. It struck Gawande that he was unprepared to help them. Patients with incurable, terminal disease given the choice of either comfort care or treatments often selected the treatments which were inherently dangerous with difficult or improbable recovery paths. Its hard for anyone involved to discuss the reality of such situations. It is far easier to hide in the details rather than focus on the limits of treatments and true implications of the terminal condition.
Gawande explains that modern scientific capabilities have turned the process of aging and dying into medical experiences. But health care is not designed to cope with old age and in trying it removes the responsibility and experience from the rest of society. Death is normal but its concrete reality is divergent from medicine as curing. Doctors strive to be competent. They aim to be knowledgeable and technically skilled. Those goals are misaligned with accepting death. For the dying such system problems are experienced as callousness and inhumanity and can result in extraordinary suffering.
The independent self
Indian tradition supports the old as the center of the extended family. The family ensure their [grand]parents can be as independent as possible. Gawande notes that this system scaled in the past because very few people previously lived into old age. In the west a number of changes undermined this framework of support:- The development of the nuclear family required that one
child remained at home to care for their parents.
- Living into old age has become more common.
- Increased longevity means that parents compete for
resources, such as the family home, with their offspring
resulting in tensions between the generations.
Increasing wealth is schematically useful information and its equivalent, schematically useful energy, to paraphrase Beinhocker. It is useful because an agent has schematic strategies that can utilize the information or energy to extend or leverage control of the cognitive niche. and property rights has enabled 'retirement'. Parents were able to collateralize their resources and live off of some of the capital is the sum total nonhuman assets that can be owned and exchanged on some market according to Piketty. Capital includes: real property, financial capital and professional capital. It is not immutable instead depending on the state of the society within which it exists. It can be owned by governments (public capital) and private individuals (private capital). . And women now have fewer children so their offspring become adults sooner increasing the possibility of retiring. Separation provided both parents and offspring with increased individual freedom.
This western trend of individual agency is now happening in China, Japan and Korea.
The US is the United States of America.
Robert Gordon argues that the inventions of the second
industrial revolution were the foundation for
American economic growth. Gordon shows how flows of people
into difficult rural America built a population base
which then took the opportunity to move on to urban settings: Houses, Food in supermarkets,
Clothes in
department stores;
that supported increasing productivity and standard of living.
The deployment of nationwide networks: Rail, Road, Utilities;
terminating in the urban housing and work places allowing the workers to
leverage time saving goods and services, which helped grow
the economy.
Gordon describes the concomitant transformation of:
Counter intuitively the constraints introduced before and in the Great Depression and the demands of World War 2 provide the amplifiers that drive the inventions deeply and fully into every aspect of the economy between 1940 and 1970 creating the exceptional growth and standard of living of post war America.
Subsequently the rate of growth was limited until the shift of women into the workplace and the full networking of voice and data supported the Internet and World Wide Web completed the third industrial revolution, but the effects were muted by the narrow reach of the technologies.
The development of Big Data, Robots, and Artificial Intelligence may support additional growth, but Gordon is unconvinced because of the collapse of the middle class.
Following our summary of Gordon's book RSS frames his arguments from the perspective of complex adaptive system (CAS) theory.
market
economy developed
retirement communities designed to venerate the independent
self. Gordon describes the concomitant transformation of:
- Communications
and advertising
- Credit
and finance
- Public health and the health care network
- Health insurance
- Education
- Social
and welfare services
Counter intuitively the constraints introduced before and in the Great Depression and the demands of World War 2 provide the amplifiers that drive the inventions deeply and fully into every aspect of the economy between 1940 and 1970 creating the exceptional growth and standard of living of post war America.
Subsequently the rate of growth was limited until the shift of women into the workplace and the full networking of voice and data supported the Internet and World Wide Web completed the third industrial revolution, but the effects were muted by the narrow reach of the technologies.
The development of Big Data, Robots, and Artificial Intelligence may support additional growth, but Gordon is unconvinced because of the collapse of the middle class.
Following our summary of Gordon's book RSS frames his arguments from the perspective of complex adaptive system (CAS) theory.
But Gawande notes the ideal of independence ignores the reality of aging, serious illness and infirmity.
Things fall apart
Gawande discusses how modern medicine has altered the impact of aging. For all but recent history death was ever present. But now medical and public health is the proactive planning, coordination and execution of strategies to improve and safeguard the wellbeing of the public. Its global situation is discussed in The Great Escape by Deaton. Public health in the US is coordinated by the PHS federally but is mainly executed at the state and local levels. Public health includes:- Awareness campaigns about health threatening activities including: Smoking, Over-eating, Alcohol consumption, Contamination with poisons: lead; Joint damage from over-exercise;
- Research, monitoring and control of: disease agents, reservoir and amplifier hosts, spillover and other processes, and vectors; by agencies including the CDC.
- Monitoring of the public's health by institutes including the NIH. This includes screening for cancer & heart disease.
- Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.
- Development, deployment and maintenance of vaccination strategies.
- Development, deployment and maintenance of fluoridation.
- Development, deployment and maintenance of family planning services.
- Regulation and constraint of foods, drugs and devices by agencies including the FDA.
- Plaques started to gather in the coronary arteries and grew until no blood flow was possible. If this is true it makes sense to preventatively treat the buildup with angioplasty.
- Plaques form anywhere in the body due to atherosclerosis and then break up and get lodged in the coronary artery and start to clot. If this is true it makes sense to preventatively limit the buildup of plaques with drugs like statins or PCSK9 inhibitors.
etc. And even incurable diseases such as cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
can be treated to extend life, until a major organ is undermined. So old age now reflects the accumulated crumbling of one's bodies systems. And medicine is often disinterested in this unless there is something for it to cure.
Aging encourages damage of the body parts:
- Teeth get difficult to clean because the decay is not felt
as easily, and the aged person struggles to use the tooth
brush and floss.
- Teeth and bones soften as calcium ions leach from them and flow into the soft tissues where they make the rest of the body harden.
- The hardening of arteries forces the heart to pump
harder.
- Lose bone and muscle mass.
- Brain shrinks (initially the frontal lobes of the cerebral cortex is at the front of the brain. It includes the: prefrontal cortex, motor cortex. Sapolsky asserts it makes you do the harder thing when it's the right thing to do. The frontal cortex supports working memory to sustain focus on a task. It also coordinates the strategic actions necessary to achieve success. It provides impulse control, regulation of emotion, and willpower. The prefrontal cortex maintains focus by deprioritizing currently irrelevant streams of information. The frontal cortex tracks rules. Over a lifetime, that builds into a costly activity. Once it tires, responses become less prosocial. But practice shifts operation of tasks to the cerebellum. The frontal cortex signals the tegmentum and accumbens with the conclusions of its expectancy/discrepancy calculations. The frontal lobe provides executive function, considering bits of information, assessing patterns and then prioritizing the strategies. The frontal lobe is the most recent part of the brain to evolve and involves a disproportionate percentage of primate-unique genes in its development and operation. It does not complete development until the mid-20s. It includes spindle neurons. It is easily damaged. Sapolsky (Nauta) notes that its ventromedial prefrontal cortex is a quasi-member of the limbic system.
and hippocampus is a part of the medial temporal lobe of the brain involved in the temporary storage or coding of long-term episodic memory. It includes the dentate gyrus. Memory formation in the cells of the hippocampus uses the MAP kinase signalling network which is impacted by sleep deprivation. The hippocampus dependent memory system is directly affected by cholinergic changes throughout the wake-sleep cycle. Increased acetylcholine during REM sleep promotes information attained during wakefulness to be stored in the hippocampus by suppressing previous excitatory connections while facilitating encoding without interference from previously stored information. During slow-wave sleep low levels of acetylcholine cause the release of the suppression and allow for spontaneous recovery of hippocampal neurons resulting in memory consolidation. It was initially associated with memory formation by McGill University's Dr. Brenda Milner, via studies of 'HM' Henry Molaison, whose medial temporal lobes had been surgically destroyed leaving him unable to create new explicit memories. The size of neurons' dendritic trees expands and contracts over a female rat's ovulatory cycle, with the peak in size and cognitive skills at the estrogen high point. Adult neurogenesis occurs in the hippocampus (3% of neurons are replaced each month) where the new neurons integrate into preexisting circuits. It is enhanced by learning, exercise, estrogen, antidepressants, environmental enrichment, and brain injury and inhibited by various stressors explains Sapolsky. Prolonged stress makes the hippocampus atrophy. He notes the new neurons are essential for integrating new information into preexisting schemas -- learning that two things you thought were the same are actually different. Specific cells within the hippocampus and its gateway, the entorhinal cortex, are compromised by Alzheimer's disease. It directly signals area 25.
). This is often seen as multi-tasking capabilities peaking in mid-life. Once brain has shrunk the skull becomes less protective since the brain rattles about inside.
- Genetically organized shutdown.
- Gawande
notes that until recently we died on average before 30 so he
doubts that aging is normal. So he sees wear and tear
as likely culprits. He cites Leonid Gavrilov who
claims that all complex systems fail randomly and gradually
because they leverage redundancy. But over Carlo Rovelli resolves the paradox of time.time the backup systems fail too resulting in frailty and eventual collapse. Felix Silverstone a senior geriatrician at Parker Jewish Institute NY agrees. He does not see a single common cellular mechanism. Instead we just fall apart.
Rovelli initially explains that low level physics does not include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is localized
- The difference between past and future is not foundational. It occurs because of state that through our blurring appears particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations evolve together with events, not things
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one of the variables of the gravitational field. With our scale we don't register quantum fluctuations, making space-time appear determined. At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions
- A present that is common throughout the universe does not exist
- Not knowing the risk of dying in the newborn's future, demographers use the risks present at that time to predict impacts in the future of the person. No adjustment can be made for increased wellbeing.
- Saving the lives of children has a far larger effect on increasing life expectancy than extending the lives of the elderly
- Impacts that occur in a particular year, such as a epidemic or pandemic, are treated as permanent effects for that years life expectancy even though they may be handled by public health strategies and hence be transients. For life expectancy calculations in subsequent years the impact is ignored.
- Programs that reduced the impacts of infectious diseases, such as antibiotics and vaccine deployment, have reduced the variability of life expectancy following their introduction.
- Vital registration systems gather accurate data for life expectancy. But most countries do not have the infrastructure and instead estimates are generated from demographic and health surveys.
- People are still retiring at 65 creating a huge overhead.
- The number of geriatricians is falling. It is not
well reimbursed by Medicare is a social insurance program that guarantees access to health insurance for Americans aged 65 and over, and younger people with disabilities and end stage renal disease or ALS. Medicare is currently missing a cap on out-of-pocket costs and direct prescription drug coverage. It includes:
- Benefits
- Part A: Hospital inpatient insurance. As of Dec 2013 Medicare pays for home care in only limited circumstances, such as when a person needs temporary nursing care after a hospitalization. Part A covers 20 days of inpatient rehabilitation at a SNF after discharge from inpatient care at a hospital.
- Part B: Medical insurance for non-hospital services including: doctor visits, tests, injectable drugs, ambulances, physical therapy;
- Part C: Medicare Advantage
- Part D: indirect prescription drug coverage The MMA prohibits Medicare from directly negotiating drug prices.
- Eligibility
- All persons 65 years of age or older who are legal residents for at least 5 years. If they or a spouse have paid Medicare taxes for 10 years the Medicare part A payments are waived. Medicare is legislated to become the primary health plan.
- Persons under 65 with disabilities who receive SSDI.
- Persons with specific medical conditions:
- Have end stage renal disease or need a kidney transplant.
- They have ALS.
- Some beneficiaries are dual eligible.
- Part A requires the person has been admitted as an inpatient at a hospital. This is constrained by a rule that they stay for three days after admission.
- Sign-up
- Part A has automatic sign-up if the person is drawing social security. Otherwise the person must sign-up for Part A and Part B.
- Should sign-up for Part B during the Initial Enrollment Period, of seven months centered around 65th birthday, online or at a social security office. But if still covered by spouse's insurance or not yet retired then may only join during the 3 month general enrollment period (January to March) each year, with coverage initiated the following July. Incremental yearly 10% penalties apply for not signing up at 65. These penalties apply to all subsequent premiums.
- Premiums
- Part A premium
- Part B insurance premium
- Part C & D premiums are set by the commercial insurer.
etc. Also there are few tools to support doing geriatrics well and the complex diseases encountered are hard to handle. But that is a pity. Patients supported by a geriatrics team had 25% less likelihood of becoming disabled, were half as likely to develop depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult; and were 40% less likely to require home help. They obtained these results by: - Simplifying medications
- Avoiding isolation
- They controlled arthritis
- They ensured the patients ate three square meals a day. But none of these strategies is sexy and Medicare did not cover the costs. Medical centers have consequently closed their geriatrics departments.
- Gawande suggests it is too late in the US is the United States of America. to reverse the
trend. But it would still be possible for the
current geriatricians to teach PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
s their skills.
Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not include time:
time to observe a geriatrician
at work. They use specialized skills:Rovelli initially explains that low level physics does not include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is localized
- The difference between past and future is not foundational. It occurs because of state that through our blurring appears particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations evolve together with events, not things
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one of the variables of the gravitational field. With our scale we don't register quantum fluctuations, making space-time appear determined. At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions
- Check feet since if they are in poor condition it signals
that the person is not able to care for them.
- Check agility of the patient in getting onto the exam table. Loss of agility typically correlates with increased falling. Falling is the key danger:
- 40% of falls drive the person into a nursing home.
- 20% never walk again.
- The risk factors are poor balance, muscle weakness and more than four medicines. There is a 10% chance of falling without one of these factors. With all three its 100%.
- Medicines may include a diuretic. As people age these become problematic causing dehydration leading to dizziness. Geriatricians can hugely reduce the risks by thoughtfully adjusting the medicines to be age appropriate.
- Old people tend to eat too few calories. This
contributes to muscle weakness.
- They aim to help their patients to:
- Gain as much freedom from the ravages of disease as possible.
- Retain enough function for active engagement in the world. This is an unusual goal for most doctors.
Dependence
The care experienced by the elderly can be exasperating. All too often the elderly are treated like patients not persons. And their care worker does not have enough Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not include time:
time to understand the needs of the
person in their care. Self-help and partner based care
leave more control over life. They have to give up their
homes. The institutions focus is on safety and require
their residents give up:Rovelli initially explains that low level physics does not include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is localized
- The difference between past and future is not foundational. It occurs because of state that through our blurring appears particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations evolve together with events, not things
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one of the variables of the gravitational field. With our scale we don't register quantum fluctuations, making space-time appear determined. At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions
- Household possessions
- Transport independence
- Personalized and interesting meals
- Own control of activities. Many institutions organize group activities which are not valued by the residents.
act (1946) allocated huge government funds to building hospitals. That resulted in the construction of 9000 new hospitals. There emerged a new option: 'cure me'.
It was hoped that the poor house system would be made redundant with the advent of Social Security in 1935 is the social securities act of 1935 was part of the second New Deal. It attempted to limit risks of old age, poverty and unemployment. It is funded through payroll taxes via FICA and SECA into the social security trust funds. Title IV of the original SSA created what became the AFDC. The Social Security Administration controls the OASI and DI trust funds. The funds are administered by the trustees. The SSA was amended in 1965 to include:
- Title V is Maternal and child health services.
- Title XVIII is Medicare.
Assistance
Nuclear families caring for parents introduce huge stresses is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
- Parent and child trade roles
- Parent no longer master of his house
- Parent moves away from old friends and communities
- Parents often adapt to the situation by befriending visitors
- Caregiver (daughter) has little help but a demanding role and becomes more constrained:
- Coping with falls
- Woken by parents nightmares
- Having to upgrade infrastructure
- Handling prostrate issues
- Having to provide different menus for parent and family
- Managing the trips to specialists
- Finds job impacted
facilities offered an attractive way out. The concept originated by Karen Brown Wilson in Oregon in the 1980s as an alternative to nursing homes. They had the goal of providing a life of freedom and autonomy, no matter what physical limits, for their residents.
Karen's mother was a stroke is when brain cells are deprived of oxygen and begin to die. 750,000 patients a year suffer strokes in the US. 85% of those strokes are caused by clots. There are two structural types: Ischemic and hemorrhagic. Thrombectomy has been found to be a highly effective treatment for some stroke situations (Jan 2018).
victim who hated traditional nursing homes. The problem is they were designed to control.
The vision was of an alternative small place with a little kitchen and bathroom. A place where she could keep her cat, and her unfinished projects, coffee pot, cigarettes; Where she could lock the door, control her heat and have her furniture. It was a vision of a person in control again rather than a patient.
Karen designed and built such a facility with her husband. Retirement community developers disliked her proposal. Once built Oregon would not license the facility she named Park Place. But explains Gawande by 1983 she had overcome all the hurdles. And Park Place was a sellout. It offered a life of freedom but added help with food, personal care, medications, and provided an onsite nurse and urgent care button. Called 'assisted living' it was attacked for failing to protect the elderly. But in 1988 results showed satisfaction with lives was higher and health had been sustained while the costs were 20% lower.
Gawande explains that while fit young people are keen to attain aspirational goals as life is threatened goals and priorities adapt. They narrow in from achievement and building networks. Any assisted living facility must provide everyday comforts and companionship. By doing this Park Place was very successful.
By 1990 Karen's company Assisted Living Concepts was a Wall Street success. But by 2003 Nursing homes had used marketing to relabel themselves as assisted living. By this time only 11% of "assisted living" facilities provided the capabilities that Karen had designed. Wilson comments that it is not surprising:
- It is difficult to do.
- Caregivers have to think and act differently. They have to be less efficient and more attentive.
- Children of the elderly are interested in their parents'
safety.
- Parents allow their children to make the choices.
A better life
Gawande similarly describes how a driven visionary Bill Thomas transformed a nursing home. He became the medical director of Chase Memorial nursing home which was looking after 80 severely disabled residents. Half were physically disabled. Four out of five had Alzheimer's is a dementia which correlates with deposition of amyloid plaques in the neurons. As of 2015 there are 5 million Alzheimer's patients in the USA. It was originally defined as starting in middle age which is rare, so it was a rare dementia. But in 1980s it was redefined as any dementia without another known cause. Early indications include mood and behavioral changes (MBI) and declarative memory and thinking problems (MCI). Specific cells within the hippocampal circuitry and its gateway, the entorhinal cortex, are damaged. The amygdala, cerebelum and other areas supporting implicit memory are not impacted during the early stages of the disease. Grid cell destruction results in a sense of being lost. The default mode network is disrupted. Variants include: late-onset sporadic; with risk factors - ApoE4 for late onset Alzheimer's, presenilin, androgen deprivation therapy (Dec 2015), type 2 diabetes. There are multiple theories of the mechanism of Alzheimer's during aging: Allen Roses argues that it is due to gene alleles that limit the capacity of mitochondria to support neuron operation, Neurons of sporadic Alzheimer's sufferers show greater APP gene diversity due to somatic recombination; It may be initiated by: stress induced HHV-6a, HHV7 herpes activation (Jun 2018) and or an increasingly leaky blood-brain barrier; and a subsequent innate immune response to the infections (May 2016). The Alzheimer's pathway follows:- Plaques form. These are seen in fMRIs 10 to 15 years prior to detecting memory and thinking changes. APP deployed in the cell membrane is cut into three parts. The external part becomes amyloid-beta peptide which aggregates into Amyloid plaques, external to the neurons, if too much is generated or it is not removed fast enough.
- Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
- Encouraging the garbage collection of amyloid and tau with gamma rhythms stimulation retards Alzheimer's in mice studies (Mar 2019)
- BACE inhibitors block an enzyme needed to form amyloid.
- Mutation driven misfolded Tau proteins can form tangles within the cytoplasm of neurons. The Tau tangles kill nerve cells. LMTX is a drug treatment targeted at these tangles.
- The brain becomes inflamed resulting in the killing of many more nerve cells. The hippocampus disintegrates and the brain loses critical functions and memory loss becomes noticeable.
- Plants - vegetable garden and plants.
- Animals - Dogs, cats and 100 birds.
- Children.
- Residents began to wake up and come to life
- People who were considered incapable of speech started
speaking.
- People who had been completely withdrawn and
non-ambulatory started walking the dogs.
- Residents named the birds.
- The number of prescriptions per resident halved.
Psychotropic drug need fell more. Deaths fell by
15%
- Most nursing homes are designed like hospitals. They are designed around the nursing station. They are institutions and aim to limit risk and serve the patient's childrens' interest in the safety of their parents. But they actually undermine will to live.
- Greenhouses are smaller and designed around the kitchen. They allow knives. Patients keep their own shoes - even though they may increase the likelihood of falling. Patients bring in their own furniture. Greenhouse nursing home developers had to educate the regulators and health officials about the goal of improved purpose of life rather than patients being destroyed by 'safety' (really boredom, loneliness and helplessness).
Gawande describes one The Leonard Florence Center for Living:
- It has all single rooms - a typical issue for residents of
regular nursing homes.
- Caregivers are given control of their schedule. They
are encouraged to be focused on just a few residents and to
do the cooking, cleaning, helping and friending.
Gawande concludes that typical medicine is mismatched to owning the care of the aged. Medicine's focus is narrow -- on repair of health. Death is related to greater things by transcendence. The probability of death induces a need to feel meaningful and worthwhile. This is often achieved by seeking a cause beyond you. Gawande explains how Peter Sanborn Place's determined and informed manager had used trained staff and smart goals to support the infirm, without it ever becoming a nursing home or assisted living is an alternative to parents joining their children's nuclear family or entering a SNF, or Greenhouse Nursinghome. Atul Gawande's Being Mortal describes the situation. Federal Medicaid does not directly cover assisted living. State Medicaid adds coverage through a federal waiver. Congressional legislation covering assisted living is limited. Assisted living providers are represented by the National Center for Assisted Living.
facility. Again Peter Sanborn Place had to battle the medical system:
- It had to individually intervene with local hospitals
and ambulance services who otherwise pushed the residents
they treated into traditional long term care
facilities.
- It had residents replace PCP is a Primary Care Physician. PCPs are viewed by legislators and regulators as central to the effective management of care. When coordinated care had worked the PCP is a key participant. In most successful cases they are central. In certain Medicare ACO models (Pioneer) PCPs are committed to achieve meaningful use requirements. Working against this is the: replacement of diagnostic skills by technological solutions, low FFS leverage of the PCP compared to specialists, demotivation of battling prior authorization for expensive treatments.
s who would not accept their unconventional model of care.
- Long term care Hospital (LTCH),
- Inpatient rehabilitation facility (IRF),
- Skilled nursing facility (SNF),
- Home health agency (HHA) - most acute care hospitals and EMR providers have strategies for integration with home based care,
- Outpatient rehabilitation. SNF and HHA represent 80% of discharges and expenditures. Assisted living is not part of federal Medicaid, but states often include it through a waiver.
and depression is a debilitating episodic state of extreme sadness, typically beginning in late teens or early twenties. This is accompanied by a lack of energy and emotion, which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels, estrogen sensitive CREB-1 gene which increases women's incidence of depression at puberty; and an accumulation of traumatic events. There is a significant risk of suicide: depression is involved in 50% of the 43,000 suicides in the US, and 15% of people with depression commit suicide. Depression is the primary cause of disability with about 20 million Americans impacted by depression at any time. There is evidence of shifts in the sleep/wake cycle in affected individuals (Dec 2015). The affected person will experience a pathological sense of loss of control, prolonged sadness with feelings of hopelessness, helplessness & worthlessness, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. Michael Pollan concludes depression is fear of the past. It affects 12% of men and 20% of women. It appears to be associated with androgen deprivation therapy treatment for prostate cancer (Apr 2016). Chronic stress depletes the nucleus accumbens of dopamine, biasing humans towards depression. Depression easily leads to following unhealthy pathways: drinking, overeating; which increase the risk of heart disease. It has been associated with an aging related B12 deficiency (Sep 2016). During depression, stress mediates inhibition of dopamine signalling. Both depression and stress activate the adrenal glands' release of cortisol, which will, over the long term, impact the PFC. There is an association between depression and additional brain regions: Enlarged & more active amygdala, Hippocampal dendrite and spine number reductions & in longer bouts hippocampal volume reductions and memory problems, Dorsal raphe nucleus linked to loneliness, Defective functioning of the hypothalamus undermining appetite and sex drive, Abnormalities of the ACC. Mayberg notes ACC area 25: serotonin transporters are particularly active in depressed people and lower the serotonin in area 25 impacting the emotion circuit it hubs, inducing bodily sensations that patients can't place or consciously do anything about; and right anterior insula: which normally generates emotions from internal feelings instead feel dead inside; are critical in depression. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Sufferers of mild autism often develop depression. Treatments include: CBT which works well for cases with below average activity of the right anterior insula (mild and moderate depression), UMHS depression management, deep-brain stimulation of the anterior insula to slow firing of area 25. Drug treatments are required for cases with above average activity of the right anterior insula. As of 2010 drug treatments: SSRIs (Prozac), MAO, monoamine reuptake inhibitors; take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. By 2018, Kandel notes, Ketamine is being tested as a short term treatment, as it acts much faster, reversing the effect of cortisol in stimulating glutamate signalling, and because it reverses the atrophy induced by chronic stress. Genomic predictions of which treatment will be effective have not been possible because: Not all clinical depressions are the same, a standard definition of drug response is difficult;. Newbridge leverages children's participation to inspire life.
Letting go
Gawande comments that reviewing the needs of the elderly introduces a question for medicine. When should doctors try to fix and when should they not?25% of all medicine spending is for the 5% of patients who are in their final year of life, and most of it is spent on care that is of apparently little benefit.
Gawande illustrates the issue with a typical cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
cost curve.
- Year 1 $28,000 for diagnostics, surgery, radiation and chemotherapy is the treatment of cancers by highly cytotoxic chemicals: Paclitaxel, Platinum, 6-mercaptopurine; assuming that cancer cells are unusually active and will be differentially poisoned. It has been successful in offering treatments when no other course was available, but non-specificity means that healthy cells also get poisoned resulting in side effects which increase with age: Permanent nerve damage, heart failure (4-5%) and leukemia (0.5-1%).
.
- Year 2 .. n -1 $2000 a year
- Year n $94,000 for metastatic breast cancer is a variety of different cancerous conditions of the breast tissue. World wide it is the leading type of cancer in women and is 100 times more common in women than men. 260,000 new cases of breast cancer will occur in the US in 2018 causing 41,000 deaths. The varieties include: Hormone sensitive tumors that test negative for her2 (the most common type affecting three quarters of breast cancers in the US, BRCA1/2 positive, ductal carcinomas including DCIS, lobular carcinomas including LCIS. Receptor presence on the cancer cells is used as a classification: Her2+/-, estrogen (ER)+/-, progesterone (PR)+/-. Metastasis classes the cancer as stage 4. Genetic risk factors include: BRCA, p53, PTEN, STK11, CHEK2, ATM, GATA3, BRIP1 and PALB2. Treatments include: Tamoxifen, Raloxifene; where worrying racial disparities have been found (Dec 2013). International studies indicate early stage breast cancer typed by a genomic test: Oncotype DX, MammaPrint; can be treated without chemotherapy (Aug 2016, Jun 2018).
have a worse quality of life for their final week than those who do not get intervention. The intervention fails to achieve the patients typical goals:
- Avoid suffering
- Strengthening relationships with family and friends
- Being mentally aware
- Not being a burden on others
- Achieving a sense that their life is complete
Gawande notes that swift catastrophic illness is now the exception. Instead one can expect a long struggle with:
- Advanced cancer
- Dementia is a classification of memory impairment, constrained feelings and enfeebled or extinct intellect. The most common form for people under 60 is FTD. Dementia has multiple causes including: vascular disease (inducing VCI) including strokes, head trauma, syphilis and mercury poisoning for treating syphilis, alcoholism, B12 deficiency (Sep 2016), privation, Androgen deprivation therapy (Oct 2016), stress, Parkinson's disease, Alzheimer's disease, and prion infections such as CJD and kuru. The condition is typically chronic and treatment long term (Laguna Honda ward) and is predicted by Stanley Prusiner to become a major burden on the health system. It may be possible to constrain the development some forms of dementia by: physical activity, hypertension management, and ongoing cognitive training. Dementia appears to develop faster in women than men.
- Parkinson's
disease corresponds to the breakdown of certain interneurons in the brain. It is not fully understood why this occurs. Dopamine system neuron breakdown generates the classical symptoms of tremors and rigidity. In some instances an uncommon LRRK2 gene mutation confers a high risk of Parkinson's disease. In rare cases Italian and Greek families are impacted in their early forties and fifties resulting from a single letter mutation in alpha-synuclein which alters the alpha-synuclein protein causing degeneration in the substantia nigra, after a build up of Lewy bodies in the neurons. But poisoning from MPTP has also been shown to destroy dopamine system neurons. DeLong showed that MPTP poisoning results in overactivity in the subthalamic nucleus. People who have an appendectomy in their 20s are at lower risk of developing Parkinson's disease. The Alpha-synuclein protein is known to build up in the appendix in association with changes in the gut microbiome. This buildup may support the 'flow' of alpha-synuclein from the gut along neurons that route to the brain. Paraquat has also been linked to Parkinson's disease. Parkinson's disease does not directly kill many sufferers. But it impacts swallowing which encourages development of pneumonia through inhaling or aspirating food. And it undermines balance which can increase the possibility of falls. Dememtia can also develop. Treatment with deep-brain stimulation, after surgical implantation of electrodes in the subthalamic nucleus removes the symptoms of Parkinson's disease in some patients.
- Progressive organ failure: heart > lungs/kidneys provides multiple vital functions. It: Produces renin which supports negative feedback, Removes excess organic molecules from the blood, Regulates electrolytes in the blood, Maintains pH homeostasis, Regulates fluid balance, Regulates blood pressure, monitors blood oxygen concentration and signals erythropoiesis with EPO, Reabsorbs water, glucose (SGLT2) and amino acids. Kidney function is monitored with the GFR. Kidneys can fail acutely or chronically. Kidneys are affected by a variety of cancers including: advanced kidney cancer, von Hippel Landau; some of which are induced by PFAS. Multiple myeloma, type 2 diabetes, TB and drug treatments for MDR TB place a strain on the kidneys and can induce failure. > liver is an emergent cellular system providing metabolic: Dietary compound metabolism and signalling: After gorging on sugar-rich foods the liver releases FGF21 hormone to dampen further eating activity; Detoxification, Regulation of glucose through glycogen storage (asprosin signalling from white adipose tissue); clotting, immune, exocrine and endocrine functions. It is supplied with oxygen-rich blood via the hepatic artery and blood rich in semi-processed foodstuffs from the intestines & spleen via the hepatic portal vein. It is constructed from: Hepatocytes which swim in the blood to process it, BECs, Stromal cells, Hepatic stellate cells, Kupffer cells, and blood vessels. The embryonic endoderm cells invade the mesoderm to form the liver bud. Subsequently the liver bud vascularizes and is colonized by hematopoietic cells. The liver operates on a daily cycle (Aug 2018) allowing it time to recover from the stress of processing toxic substances. In a healthy adult liver cells do not divide significantly. But in a damaged liver, the liver cells shift back to a neonatal state to re-enter the cell cycle and rebuild the liver. There are over 100 disorders of the liver. Obesity and diabetes are associated with increased prevalence of these liver disorders worldwide.
. - Old age
In comparison hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now. There are major hospice chains focused on providing palliative care.
has the key goal of helping people with a fatal illness to have the fullest possible life right now. But it too has to fight against the momentum of medical treatment.
A visiting hospice nurse has a set of key questions:
- Are you in pain emerged as a mental experience, Damasio asserts, constructed by the mind using mapping structures and events provided by nervous systems. But feeling pain is supported by older biological functions that support homeostasis. These capabilities reflect the organism's underlying emotive processes that respond to wounds: antibacterial and analgesic chemical deployment, flinching and evading actions; that occur in organisms without nervous systems. Later in evolution, after organisms with nervous systems were able to map non-neural events, the components of this complex response were 'imageable'. Today, a wound induced by an internal disease is reported by old, unmyelinated C nerve fibers. A wound created by an external cut is signalled by evolutionarily recent myelinated fibers that result in a sharp well-localized report, that initially flows to the dorsal root ganglia, then to the spinal cord, where the signals are mixed within the dorsal and ventral horns, and then are transmitted to the brain stem nuclei, thalamus and cerebral cortex. The pain of a cut is located, but it is also felt through an emotive response that stops us in our tracks. Pain amplifies the aggression response of people by interoceptive signalling of brain regions providing social emotions including the PAG projecting to the amygdala; making aggressive people more so and less aggressive people less so. Fear of pain is a significant contributor to female anxiety. Pain is the main reason people visit the ED in the US. Pain is mediated by the thalamus and nucleus accumbens, unless undermined by sleep deprivation.
? - How is your appetite, thirst, sleeping?
- Any trouble with confusion, anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Anxiety disorders are now seen as a related cluster, including PTSD, panic attacks, and phobias. Major anxiety, is typically episodic, correlated with increased activity in the amygdala, results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women. Women are four times more likely to suffer from anxiety. Louann Brizendine concludes this helps prepare mothers, so they are ready to protect their children. Michael Pollan concludes anxiety is fear of the future. Sufferers of mild autism often develop anxiety disorders. Treatments for anxiety differ. 50 to 70% of people with generalized anxiety respond to drugs increasing serotonin concentrations, where there is relief from symptoms: worry, guilt; linked to depression, which are treated with SSRIs (Prozac). Cognitive anxiety (extreme for worries and anxious thoughts) is also helped by yoga. But many fear-related disorders respond better to psychotherapy: psychoanalysis, and intensive CBT. Tara Brach notes that genuine freedom from fear is enabled by taking refuge.
or restlessness? - Chest pain or heart palpitations?
- Trouble with constipation, urination or walking?
- Checks if taking medicines
75% of people enter hospice with a terminal illness but not accepting that they are dying. Typically feel that doctors have abandoned them. A hospice nurse has about 5 seconds to get a new patient to like is an emotion which initiates and maintains an altruistic partnership. It is a willingness to offer someone a favor. It is directed to those who appear likely to return the favor. and trust and distrust are evolved responses to sham emotions. During a friendship where no sham emotions have been detected trust will build up.
them. They have a powerful offer: "I am a hospice nurse and here's what I have to offer to make your life better and I know we don't have a lot of
Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not include time:
time to waste." Rovelli initially explains that low level physics does not include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is localized
- The difference between past and future is not foundational. It occurs because of state that through our blurring appears particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations evolve together with events, not things
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one of the variables of the gravitational field. With our scale we don't register quantum fluctuations, making space-time appear determined. At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions
The nurse must evaluate the patient's family for its ability to support the care. They will provide a comfort pack and a help line for how to use it. The pack includes:
- Morphine for pain
- Ativan for anxiety
- Compazine for nausea
- Haldol for delirium
- Tylenol for fever
- Atropine for death rattle
But it is not easy for the elderly, their care givers or doctors to decide on the right approach. There are new experimental therapies. S. J. Gould was told he had a terminal cancer but he lived due to the long tail of possibility. These possibilities offer hope in treatment.
And the strategy of withholding treatment because it is costly and has no statistical validity was undermined when Healthnet took this approach in 1991 and their patient died. The family was awarded $89 million by a jury.
Aetna in 2004 found that offering hospice in addition to, rather than as an alternative to treatment, resulted in less visits to the ER is emergency department. Pain is the main reason (75%) patients go to an E.D. It has traditionally been part of an acute care hospital but recently is being deployed standalone as a catchment funnel to the owning hospital. The EMTALA legislation requires E.D. treatment to stabilize every person seeking treatment by most hospitals. Unreimbursed care is supported from federal government funds. E. D. profitability has been helped by hospitals contracting with 3rd party companies who are able to improve margins through surprise billing. The standalone E.D. competes with the positioning and brand power of lower cost urgent care clinics. Commercial nature of care requires walk-ins to register to gain access to care. With the focus on treatment of pain, E.D.s are a major distributor of opioids (5% of opioid prescriptions) and a major starting point of addiction in patients but are cutting back (Jun 2016).
, ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs.
and costs fell 25%.
The key need in either strategy is to help people negotiate overwhelming anxiety. Gawande notes it has to be a process. You must sit down and take time and the doctor must mostly listen. The aim is to find out what is important to them in the circumstances. Then can provide information and advice on the best chance of achieving their desires.
Their circumstances will depend on what they understand their prognosis to be. As such they will have concerns about what lies ahead. It is important to understand what tradeoffs they are willing to make. How do they want to spend their time? Who do they want to make decisions for them if they become incapacitated?
Hard conversations
The world is now following the US is the United States of America. trend of deploying hospitals. The US is adopting hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now. There are major hospice chains focused on providing palliative care.: 45% of deaths by 2010 will be hospice supported. But Gawande warns there is no process to link the hospital and hospice approaches. With his father developing a terminal cancer is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016).
Gawande experienced the problem at first hand.
He describes three approaches taken by the hospital doctors:
- 'Dr. knows best' enforces a treatment plan that moves the
patient to the ICU is intensive care unit. It is now being realized that the procedures and environment of the ICU is highly stressful for the patients. In particular sedation with benzodiazepines is suspected to enhance the risk of inducing PTSD. Intubation and catheterization are also traumatic. Sometimes seperated into MICU and SICU. eICU skill centralization may bring down costs.
. - 'Dr. informative' who presents details of treatments and
their statistical effects. This approach leaves the
patient anxious and bewildered but also heading towards the
ICU.
- 'Dr. complexity' who:
- Asks questions to identify the patients goals and fears
- Takes Carlo Rovelli resolves the paradox of time.time to slowly adjust as the patient adapts.
Rovelli initially explains that low level physics does not include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is localized
- The difference between past and future is not foundational. It occurs because of state that through our blurring appears particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations evolve together with events, not things
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one of the variables of the gravitational field. With our scale we don't register quantum fluctuations, making space-time appear determined. At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions
- A present that is common throughout the universe does not exist
- Aligns strategic options with the goals and fears
identified earlier.
- Agrees a plan with the patient. Gawande stresses this is not just a set of options which would result in inducing panic. Instead treatments are described with benefits of success and risks and impacts. And alternative palliative aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis. /hospice options are evaluated. The situation must cope with adaption. At each point Gawande stresses it is important to ask the patient:
- What goals are important?
- What tradeoffs are they willing to make?
Courage
Gawande identifies two kinds of courage required to cope with aging and sickness:- To confront reality of our mortality -- the courage to
seek out the truth of what is to be feared and what is to be
hoped
- To act on the truth we find
Carlo Rovelli resolves the paradox of time.
Rovelli initially explains that low level physics does not include time:
time also affects how our goals and
fears are evaluated. Rovelli initially explains that low level physics does not include time:
- A present that is common throughout the universe does not exist
- Events are only partially ordered. The present is localized
- The difference between past and future is not foundational. It occurs because of state that through our blurring appears particular to us
- Time passes at different speeds dependent on where we are and how fast we travel
- Time's rhythms are due to
the gravitational field
- Our quantized physics shows neither
space nor time, just processes transforming physical
variables.
- Fundamentally there is no time. The basic equations evolve together with events, not things
- Our familiar time emerges
- Our interaction with the world is partial, blurred,
quantum indeterminate
- The ignorance determines the existence of thermal time
and entropy that quantifies our uncertainty
- Directionality of time is real
but perspectival. The entropy of the world in
relation to us increases with our thermal time. The
growth of entropy distinguishes past from future: resulting in
traces and memories
- Each human is a
unified being because: we reflect the world, we
formed an image of a unified entity by
interacting with our kind, and because of the perspective
of memory
- The variable time: is one of the variables of the gravitational field. With our scale we don't register quantum fluctuations, making space-time appear determined. At our speed we don't perceive differences in time of different clocks, so we experience a single time: universal, uniform, ordered; which is helpful to our decisions
Gawande reflects that assisted suicide has multiple problems seen in this light. It:
- Should not be allowed for healthy people who are likely to
reevaluate their situation in the future.
- Presents a valuable option for the terminally ill who are
suffering. But Gawande notes in societies where it has
been deployed it tends to undermine the development of hospice has the key goal of helping people with a fatal illness to have the fullest possible life right now. There are major hospice chains focused on providing palliative care.
type strategies that could reduce the suffering and allow the patient to achieve more of their immediate goals.
Epilogue
Gawande argues being mortal is about the struggle of coping with the constraints of our biology. Medical science can push against the limits. But there is harm induced when we fail to acknowledge the limits.Gawande suggests the job of medicine has been misunderstood. It is easy to assume that it is to ensure health and survival. Really it is to assure wellbeing indicates the state of an organism is within homeostatic balance. It is described by Angus Deaton as all the things that are good for a person:
- Material wellbeing includes income and wealth and its measures: GDP, personal income and consumption. It can be traded for goods and services which recapture time. Material wellbeing depends on investments in:
- Infrastructure
- Physical
- Property rights, contracts and dispute resolution
- People and their education
- Capturing of basic knowledge via science.
- Engineering to turn science into goods and services and then continuously improve them.
- Physical and psychological wellbeing are represented by health and happiness; and education and the ability to participate in civil society through democracy and the rule of law. University of Wisconsin's Ryff focuses on Aristotle's flourishing. Life expectancy as a measure of population health, highly weights reductions in child mortality.
Complex adaptive system
This page introduces the complex adaptive system (CAS) theory
frame. The theory provides an organizing framework that is
used by 'life.' It can be used to evaluate and rank models
that claim to describe our perceived reality. It catalogs
the laws and strategies which underpin the operation of systems
that are based on the interaction of emergent
agents. It highlights the
constraints that shape CAS and so predicts their form. A
proposal that does not conform is wrong.
John Holland's framework for representing complexity is outlined. Links to other key aspects of CAS theory discussed at the site are presented.
(CAS) theory
supports reasoning about agency, death, evolution, cooperation
and adaptations in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage. Holland argues: complex adaptive systems (CAS) adapt due to the influence of schematic strings on agents. Evolution indicates fitness when an organism survives and reproduces. For his genetic algorithm, Holland separated the adaptive process into credit assignment and rule discovery. He assigned a strength to each of the rules (alternate hypothesis) used by his artificial agents, by credit assignment - each accepted message being paid for by the recipient, increasing the sender agent's rule's strength (implicit modeling) and reducing the recipient's. When an agent achieved an explicit goal they obtained a final reward. Rule discovery used the genetic algorithm to select strong rule schemas from a pair of agents to be included in the next generation, with crossing over and mutation applied, and the resulting schematic strategies used to replace weaker schemas. The crossing over genetic operator is unlikely to break up a short schematic sequence that provides a building block retained because of its 'fitness'; In Deacon's conception of evolution, an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary. John Holland's framework for representing complexity is outlined. Links to other key aspects of CAS theory discussed at the site are presented.
to new technologies.
Death is typically an architected aspect of a CAS
Plans are interpreted and implemented by agents. This page
discusses the properties of agents in a complex adaptive system
(CAS).
It then presents examples of agents in different CAS. The examples include a computer program where modeling and actions are performed by software agents. These software agents are aggregates.
The participation of agents in flows is introduced and some implications of this are outlined.
agent. Indeed when such aspects
fail as in many metastatic cancers is the out-of-control growth of cells, which have stopped obeying their cooperative schematic planning and signalling infrastructure. It results from compounded: oncogene, tumor suppressor, DNA caretaker; mutations in the DNA. In 2010 one third of Americans are likely to die of cancer. Cell division rates did not predict likelihood of cancer. Viral infections are associated. Radiation and carcinogen exposure are associated. Lifestyle impacts the likelihood of cancer occurring: Drinking alcohol to excess, lack of exercise, Obesity, Smoking, More sun than your evolved melanin protection level; all significantly increase the risk of cancer occurring (Jul 2016). It then presents examples of agents in different CAS. The examples include a computer program where modeling and actions are performed by software agents. These software agents are aggregates.
The participation of agents in flows is introduced and some implications of this are outlined.
the planning and cooperation typical of CAS as well as the system itself collapses. For multi-cellular agents and superorganisms is a wealthy autonomous entity needing and controlling the richest niches in the proximate environment, that emerges from the bundled cooperation of schematically aligned agents. The term is based on the social insect model, used by: ants, termites, and bees; and identified by Holldobler & E.O. Wilson. These genetically identical insect superorganisms cooperatively limit their reproduction to align with the resources available in the niche. Wilson asserts these insects all developed nests to which they returned to raise their offspring, and when the nest sites were of limited capacity some family members responded by focusing on defending the nest and foraging while their mother became an egg laying queen, enabled by "a single genetic change which silenced the brain's program for dispersal and prevents the mother and her offspring from dispersing to create new nests," Wilson explains. He adds climate control of the nest and disease resistance, just like the human immune system, demand individually focused diversity. So the queen's genome consists of low variety alleles for the extended phenotypic 'robot' worker caste agents and their organization - queen and workers competing as one, with other colonies and individual insects - and other parts which are high where the genome includes significant diversity. For humans it is an evolved cultural strategy used when the environment is supportive, but it is dependent on our imperfect cognitive assessment of kinship as well as group selection driven emotions: other-condemning, other-praising, other-suffering and self-conscious; and group oriented pressures to conform and remain: religions. And the adjacent possible must be recreated and modeled culturally through the emergence of processes such as democracy. It depends on inter-agent signalling. In both insects and humans it allows specialization, and encourages operations and flows that are tightly controlled, limiting waste, leveraging parallel activity, supporting coherence. Superorganisms reflect cliodynamic flows. A superorganism has a development and operational phase. As additional agents are coopted into the superorganism they align, participate in supply and demand activities and so contribute to the evolutionary amplification. Damasio notes that prokaryotes, in rich environments, can similarly operate in a symbiotic fashion expressing cultural behaviors.
death also provides a key support for
In this page we summarize the arms race between hosts
and their parasites.
The deadly nature and adaptive
pressure of the relationship is introduced. How the
slowly reproducing hosts cope is
described. Cultural
hosts and parasites are discussed.
sexual
reproduction's competitive response to parasites.
And it appears important in moving the parents out of the way
and thus allowing the offspring access to the resources they
will need to survive and reproduce. From the perspective of the system once the agent has replicated, its
Plans emerge in complex adaptive
systems (CAS) to provide the
instructions that agents use to
perform actions. The component architecture and structure
of the plans is reviewed.
schematic plan is
perpetuated. The agent need only persist while it is
providing material support to the developing offspring.
But as Gawande notes the structure of the family has been
transformed from the large
extended to the small nuclear. There are significant
unintended consequences. One appears to be the limited
opportunity for cross infection from one familial infant to
another. Key participants of the human microbiome, the trillions of bacteria and viruses that live inside higher animals' guts, on their skin etc. These bacteria and viruses seem to play a role in: immune responses, digesting food, making nutrients, controlling mental health and maintaining a healthy weight. The signals from the gut microbiota are relayed by major nerve fibers: vagus; to the central nervous system. The symbiotic relationship must be actively managed. Human armpits include glands which provide food favoring certain symbionts who build a defensive shield above the skin. In the human gut: Barriers are setup: Mucus secretions form a physical constraint and provide sites for bacteriophages to anchor and attack pathogenic bacteria; Symbiont tailored nourishment: Plant-heavy food creates opportunities for fibre specialists like Bacteroides thetaiotaomicron; is provided, Selective binding sites are provided, Poisons are deployed against the unwelcome, and Temperature, acidity and oxygenation are managed. High throughput sequencing allows the characterization of bacterial populations inside guts. Beginning at birth, as they pass down the birth canal infants are supplied with a microbiome from their mothers. If they are borne via cesarean they never receive some of the key bacteria: Bifidobaterium infantis which is also dependent on oligosaccharides in breast milk; from their mothers. A variety of diseases may be caused by changes in the microbiome: - Eczema can be related to changes in the skin microbiome.
- Obesity can be induced by changes to the gut microbiome.
- Chronic inflammation
- Allergies
- Type 1 diabetes
, Helicobacter pylori is a gram-negative bacteria, found in the stomach microbiome. Having been identified as the causative agent of stomach ulcers and stomach cancer it has been a focus of eradication campaigns. However, it has been subsequently realized that it limits acid reflux and esophageal cancer, and may be a necessary component of the infant microbiome.
; are collapsing as their transmission chains have failed.
Gawande suggests that aging is an unusual event for humans and that complex systems are redundant and fail randomly and gradually in fragile ways. The high death rates of infants and old people distort average death rates. Most adults in previous ages did not die at 30. A lot of infants died lowering the average. For CAS agents tailored and customized through the execution of genetic plans which specified their emergence by aggregation of cooperating lower level agents' randomness can only be part of the picture. Whenever agent death is valuable from the systems perspective it can surely be invoked. Such mechanisms exist. Janet Mann describes in The Adapted Mind when economically is the study of trade between humans. Traditional Economics is based on an equilibrium model of the economic system. Traditional Economics includes: microeconomics, and macroeconomics. Marx developed an alternative static approach. Limitations of the equilibrium model have resulted in the development of: Keynes's dynamic General Theory of Employment Interest & Money, and Complexity Economics. Since trading depends on human behavior, economics has developed behavioral models including: behavioral economics.
stressed is a multi-faceted condition reflecting high cortisol levels. Dr. Robert Sapolsky's studies of baboons indicate that stress helps build readiness for fight or flight. As these actions occur the levels of cortisol return to the baseline rate. A stressor is anything that disrupts the regular homeostatic balance. The stress response is the array of neural and endocrine changes that occur to respond effectively to the crisis and reestablish homeostasis.
- The short term response to the stressor
- activates the amygdala which: Stimulates the brain stem resulting in inhibition of the parasympathetic nervous system and activation of the sympathetic nervous system with the hormones epinephrine and norepinephrine deployed around the body, Activates the PVN which generates a cascade resulting in glucocorticoid secretion to: get energy to the muscles with increased blood pressure for a powerful response. The brain's acuity and cognition are stimulated. The immune system is stimulated with beta-endorphin and repair activities curtail. In order for the body to destroy bacteria in wounds, pro-inflammatory cytokines increase blood flow to the area. The induced inflammation signals the brain to activate the insula and through it the ACC. But when the stressor is
- long term: loneliness, debt; and no action is necessary, or possible, long term damage ensues. Damage from such stress may only occur in specific situations: Nuclear families coping with parents moving in. Sustained stress provides an evolved amplifier of a position of dominance and status. It is a strategy in female aggression used to limit reproductive competition. Sustained stress:
- Stops the frontal cortex from ensuring we do the harder thing, instead substituting amplification of the individual's propensity for risk-taking and impairing risk assessment!
- Activates the integration between the thalamus and amygdala.
- Acts differently on the amygdala in comparison to the frontal cortex and hippocampus: Stress strengthens the integration between the Amygdala and the hippocampus, making the hippocampus fearful.
- BLA & BNST respond with increased BDNF levels and expanded dendrites persistently increasing anxiety and fear conditioning.
- Makes it easier to learn a fear association and to consolidate it into long-term memory. Sustained stress makes it harder to unlearn fear by making the prefrontal cortex inhibit the BLA from learning to break the fear association and weakening the prefrontal cortex's hold over the amygdala. And glucocorticoids decrease activation of the medial prefrontal cortex during processing of emotional faces. Accuracy of assessing emotions from faces suffers. A terrified rat generating lots of glucocorticoids will cause dendrites in the hippocampus to atrophy but when it generates the same amount from excitement of running on a wheel the dendrites expand. The activation of the amygdala seems to determine how the hippocampus responds.
- Depletes the nucleus accumbens of dopamine biasing rats toward social subordination and biasing humans toward depression.
- Disrupts working memory by amplifying norepinephrine signalling in the prefrontal cortex and amygdala to prefrontal cortex signalling until they become destructive. It also desynchronizes activation in different frontal lobe regions impacting shifting of attention.
- Increases the risk of autoimmune disease (Jan 2017)
- During depression, stress inhibits dopamine signalling.
- Strategies for stress reduction include: Mindfulness.
At each
This page discusses the mechanisms and effects of emergence
underpinning any complex adaptive system (CAS). Physical forces and
constraints follow the rules of complexity. They generate
phenomena and support the indirect emergence of epiphenomena.
Flows of epiphenomena interact in events which support the
emergence of equilibrium and autonomous
entities. Autonomous entities enable evolution
to operate broadening the adjacent possible.
Key research is reviewed.
emergent level the agents
must be able to The agents in complex adaptive
systems (CAS) must model their
environment to respond effectively to it. Evolution's
schematic operators and Samuel
modeling together support the indirect recording of past
successes and their strategic use by the current agent to learn
how to succeed in the proximate environment.
model their
proximate environment. For multi-cellular animals this
requires the Consciousness has confounded philosophers and scientists for
centuries. Now it is finally being characterized
scientifically. That required a transformation of
approach.
Realizing that consciousness was ill-defined neuroscientist Stanislas Dehaene and others characterized and focused on conscious access.
In the book he outlines the limitations of previous psychological dogma. Instead his use of subjective assessments opened the window to contrast totally unconscious brain activity with those including consciousness.
He describes the research methods. He explains the contribution of new sensors and probes that allowed the psychological findings to be correlated, and causally related to specific neural activity.
He describes the theory of the brain he uses, the 'global neuronal workspace' to position all the experimental details into a whole.
He reviews how both theory and practice support diagnosis and treatment of real world mental illnesses.
The implications of Dehaene's findings for subsequent consciousness research are outlined.
Complex adaptive system (CAS) models of the brain's development and operation introduce constraints which are discussed.
development of neuronal
infrastructure and adaptive learning. With these
constraints it is not surprising that our ability to represent
our historic experiences uses short cuts. Our remembering
self maintains just the notable event and the end event.
Given the previous comments on death the remembering self seems
satisfactory from Realizing that consciousness was ill-defined neuroscientist Stanislas Dehaene and others characterized and focused on conscious access.
In the book he outlines the limitations of previous psychological dogma. Instead his use of subjective assessments opened the window to contrast totally unconscious brain activity with those including consciousness.
He describes the research methods. He explains the contribution of new sensors and probes that allowed the psychological findings to be correlated, and causally related to specific neural activity.
He describes the theory of the brain he uses, the 'global neuronal workspace' to position all the experimental details into a whole.
He reviews how both theory and practice support diagnosis and treatment of real world mental illnesses.
The implications of Dehaene's findings for subsequent consciousness research are outlined.
Complex adaptive system (CAS) models of the brain's development and operation introduce constraints which are discussed.
This page reviews the implications of selection, variation and
heredity in a complex adaptive system (CAS).
The mechanism and its emergence are
discussed.
evolution's
perspective. Gawande provides powerful demonstrations of the issues of
H. A. Hayek compares and contrasts collectivism and
libertarianism.
central
planning. His contrasting illustrations of local
agents (Karen Brown Wilson, Bill Thomas) developing adaptive in evolutionary biology is a trait that increased the number of surviving offspring in an organism's ancestral lineage. Holland argues: complex adaptive systems (CAS) adapt due to the influence of schematic strings on agents. Evolution indicates fitness when an organism survives and reproduces. For his genetic algorithm, Holland separated the adaptive process into credit assignment and rule discovery. He assigned a strength to each of the rules (alternate hypothesis) used by his artificial agents, by credit assignment - each accepted message being paid for by the recipient, increasing the sender agent's rule's strength (implicit modeling) and reducing the recipient's. When an agent achieved an explicit goal they obtained a final reward. Rule discovery used the genetic algorithm to select strong rule schemas from a pair of agents to be included in the next generation, with crossing over and mutation applied, and the resulting schematic strategies used to replace weaker schemas. The crossing over genetic operator is unlikely to break up a short schematic sequence that provides a building block retained because of its 'fitness'; In Deacon's conception of evolution, an adaptation is the realization of a set of constraints on candidate mechanisms, and so long as these constraints are maintained, other features are arbitrary. strategies which proved valuable and grew by replication are clearly superior approaches.
The crumbling of one's bodily systems is Aubrey de Grey's focus as discussed in our
In his talk 'The Science of Ending Aging' Aubrey de Grey argues
we should invest more in maintenance of our bodies. In
this page we summarize his video comments and then use complex
adaptive system (CAS) theory to
review his arguments. Focusing the lens of CAS theory and
mechanisms of emergence on the system we highlight the pros and
cons of ending aging.
summary of the science
of ending aging. Being Mortal provides a sophisticated and visionary description of the challenge of aging in our high technology society and how we should organize to cope with it. I hope my health care providers have read and thought about Atul Gawande's important points.
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This page looks at schematic structures
and their uses. It discusses a number of examples:
As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan.
Finally it includes a section presenting our formal representation of schematic goals.
Each goal has a series of associated complex adaptive system (CAS) strategy strings.
These goals plus strings are detailed for various chess and business examples.
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Design |
- Schematic ideas are recombined in creativity.
- Similarly designers take ideas and rules about materials and components and combine them.
- Schematic Recipes help to standardize operations.
- Modular components are combined into strategies for use in business plans and business models.
As a working example it presents part of the contents and schematic details from the Adaptive Web Framework (AWF)'s operational plan.
Finally it includes a section presenting our formal representation of schematic goals.
Each goal has a series of associated complex adaptive system (CAS) strategy strings.
These goals plus strings are detailed for various chess and business examples.
This page uses an example to illustrate how:
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- Business planning activities performed by the whole organization can build awareness, empowerment and coherence.
- A program approach can ensure strategic alignment.
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