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. 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 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.

The global system now encourages individual agency tearing down the extended family strategy.

Increasing wealth 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. market economy developed retirement communities designed to venerate the independent self.

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, Joint damage from over-exercise;
Research, monitoring and control of disease agents, processes and vectors by agencies including the CDC.
Monitoring of the public's health by institutes including the NIH.
Development, deployment and maintenance of infrastructure including: sewers, water plants and pipes.
Development, deployment and maintenance of vaccination strategies.
Regulation and constraint of foods, drugs and devices by agencies including the FDA.

improvements have pushed out the likelihood of immediate death. Today medicine has cut the mortality of heart attack is an AMI. It can induce cardiac arrest. Blocking the formation of clots with platelet aggregation inhibitors, can help with treating and avoiding AMI. Risk factors include: taking NSAID pain killers (May 2017). There is uncertainty about why AMI occur. Alternative hypotheses include:

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.

s, respiratory illness, stroke is when brain cells are deprived of oxygen and begin to die. There are two structural types: Ischemic and hemorrhagic.
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.
Loose 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 brain involved in the temporary storage or coding of long-term episodic memory. 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 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.
). 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.

Gawande outlines some alternative theories about why we age:

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 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.

Increased life expectancy is a measure of the average life time of a new born baby. Without public health assistance many children die in the first five years of life significantly lowering the life expectancy of the whole group. There are representational and data capture problems with the model:

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.

has altered society's demographics. But societies have not responded:

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 includes:
- Benefits
- Eligibility
- Premiums
and so medical schools are turning out highly remunerated oncologists, orthopedic surgeons, urologists 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 state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events. 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, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. 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. There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Treatments include: CBT, UMHS depression management. As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. 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 low FFS leverage of the PCP compared to specialists.
s their skills.

Gawande took the time to observe a geriatrician at work. They use specialized skills:

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.

Gawande noted that deterioration has complex implications. For example lordosis of the spine which occurs commonly with age tips the head forward. This means that when sufferers eat they are more likely to choke on food particles and cough them into the lungs where the aspirated particles can result in pneumonia is an inflamed lung. It can be caused by infection with viruses or bacteria, drugs and autoimmune diseases. HAP, including VAP can be very troubling. !

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 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:

Household possessions
Transport independence
Personalized and interesting meals
Own control of activities. Many institutions organize group activities which are not valued by the residents.

Gawande reviewed the historic development of hospitals and nursing homes. Western Europe and the US is the United States of America. replaced poor houses with care homes. It was assumed that the old needed medical care within a nursing home to ensure they were safe. Post 1945 the emergence of modern drugs encouraged the US congress to sponsor the building of hospitals. The Hill-Burton Free and Reduced-Cost Health Care act of 1946 gave health facilities including: Hospitals: General, Long-term care, Mental; Nursing homes, Outpatient facilities, Public health centers; grants and loans for construction and modernization. It specified administration through the HRSA. It was amended by Congress in 1954 to cover development of nursing homes.
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.

. But it became obvious that there were many people who were too weak, frail, senile, and broken to care for themselves. In the 1950s hospitals were used to house these people. Congress allocated Hill-Burton funds in 1954 for extended recovery facilities -- the modern nursing homes. With many states having substandard facilities funded with federal money it was felt necessary to allow the substandard nursing homes to remain funded with the 1965 inclusion of 'substantial compliance'. Access to this flow of funds encouraged an explosion in the number of nursing homes. There were 13,000 by 1970.

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. 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.

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

In this situation:

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

With nursing homes typically rejected by the parent, assisted living 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. There are two structural types: Ischemic and hemorrhagic.
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

Plaques form and set off the formation of tangled thread-like tau protein.

Solanezumab aimed to inhibit plaque formation but clinical trials failed (Nov 2016).
BACE inhibitors block an enzyme needed to form amyloid.

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.

. He was immediately concerned about the despair evident in all the residents. Eventually he concluded it was caused by 'lack of life'. He noted boredom, loneliness is an aversive signal like thirst, hunger or pain. It has been associated with the dorsal raphe nucleus (Sep 2016). Loneliness affects several important bodily functions through overstimulation of the stress response. Chronic loneliness is associated with increased cortisol levels, hypertension and impaired production of white blood cells undermining the immune system.
and helplessness. He proposed adding:

Plants - vegetable garden and plants.
Animals - Dogs, cats and 100 birds.
Children.

Again it was against all the government regulations. But the results undermined the constraints:

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%

Thomas formed the Eden Alternative. This is a not-for-profit to teach Eden principles. He founded Pioneer network which developed the Green House Greenhouse nursing homes offer personal service and private rooms. This reduces the opportunities for cross infections reducing cost of errors.

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 safety of their patients. 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 likelyhood of falling. Patients bring in their own furniture. Greenhouse nursing home developers had to enducate the regulators and health officials about the goal of improved purpose of life rather than patients being destroyed by 'safety' (really boredom, loneleness and helplessness).

. It is funded by the Robert Wood Johnson foundation. The Green House looks like a nursing home to the government but feels like a home to residents. 150 Green Houses have been developed in 25 states.

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 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 low FFS leverage of the PCP compared to specialists.
s who would not accept their unconventional model of care.

Gawande describes a further success story: Newbridge on the Charles which he introduces as a new model of nursing home architecture. It supports the full continuum of care is a Post-Acute Care provider. A three-day hospital admission and discharge are prerequisite requirements to receiving Medicare PAC services. Acute care hospitals become portals to the PAC business. Referrals are key. PAC includes different types of facility focused on different severity of illness (high to low):

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.

offering independent living, assisted living and skilled nursing. Its building is constructed as pods -- Rooms around a central dining room, kitchen and activity room. The pods are family size inducing a sense of safety, increasing socialization and friendship and reducing anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women.
and depression is a debilitating state which is facilitated by genetic predisposition - for example genes coding for relatively low serotonin levels; and an accumulation of traumatic events. 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, irritability, sleep disturbances, loss of appetite, and inability to experience pleasure. 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. There is an association between depression and particular brain regions: Hippocampal dendrite and spine number reductions, Dorsal raphe nucleus linked to loneliness, Abnormalities of the ACC. Childhood adversity can increase depression risk by linking recollections of uncontrollable situations to overgeneralizations that life will always be terrible and uncontrollable. Treatments include: CBT, UMHS depression management. As of 2010 drug treatments take weeks to facilitate a response & many patients do not respond to the first drug applied, often prolonging the agony. 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.

He explains that the cost curve does not have to look this way. A 2008 study by the National Coping with Cancer project compared terminally ill cancer patients put on a mechanical ventilator, given defibrillation, or admitted when near death to an 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.
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:

He continues that death is certain but the timing isn't. We all struggle with how and when to accept that the battle is lost. And technology can now sustain the body past the point of awareness and coherence.

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 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. Pain is the main reason people visit the ED in the US. ?
How is your appetite, thirst, sleeping?
Any trouble with confusion, anxiety is manifested in the amygdala mediating inhibition of dopamine rewards. Major anxiety results in elevated glucocorticoids and reduces hippocampal dendrite & spine density. Some estrogen receptor variants are associated with anxiety in women.
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 time to waste."
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: 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 time to slowly adjust as the patient adapts.
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?

Still Gawande concedes there is a difficult decision that must be faced. Should we focus on our vision and legacy or making our present the best experience possible. We are not built to make this decision effectively. Gawande describes the remembering self and the experiencing self from Daniel Kahneman's research and book Thinking Fast and Slow. This is what evolution has provided us with to make decisions over a long life of repeating experiences. But these patients probably only have the here and now! When time is limited they both seem important.

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

But the wise choice is frequently unclear. Should one care most about hopes or fears? The perspective of time also affects how our goals and fears are evaluated.

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 type strategies that could reduce the suffering and allow the patient to achieve more of their immediate goals.

When palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis. works the patient's goals extend. This extension enables the development of a rewarding 'dying role'.

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 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. Life expectancy as a measure of population health, highly weights reductions in child mortality.

. Then all doctors will practice palliative care aims to relieve and prevent the suffering (symptoms, pain and stress of serious illness) of patients what ever their prognosis. .

Complex adaptive system

(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. 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.

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). the planning and cooperation typical of CAS as well as the system itself collapses. For multi-cellular agents and

E. O. Wilson & Bert Holldobler illustrate how bundled cooperative strategies can take hold. Various social insects have developed strategies which have allowed them to capture the most valuable available niches. Like humans they invest in specialization and cooperate to subdue larger, well equipped competitors.

superorganisms 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. 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 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.

: Bifidobacterium infantis is a key symbiont in the human infant microbiome. It is selected for by breast milk's array of oligosaccharides. This structures the microbiome and helps bootstrap the immune system. But its transmission to further generations may depend on large families where the children typically cross infect. It appears to be collapsing in western societies with small nuclear families and a focus on cleanliness.
, 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 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. 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.

During depression, stress inhibits dopamine signalling.
Strategies for stress reduction include: Mindfulness.

mothers find they have too little food to feed their whole family they may opt for 'infanticide' of one or more of the children. And Medawar and Williams's mutations potentially set an upper limit on life span in the scenario Gawande outlines for humans (Dec 2016)

At each

This page discusses the mechanisms and effects of emergence underpinning any complex adaptive system (CAS). 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. Samuel modeling is described as an approach.

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

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 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:

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.

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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.

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