Wednesday, January 20, 2016

Unequal Lives, Unequal Deaths - The New York Times

In my first year of practice in palliative medicine, I made house calls to patients in South Los Angeles. My patients all lived in neighborhoods that ranked among the city's lowest in both income and life expectancy. In these neighborhoods, people die an average of 10 years earlier than those who live less than 10 miles away. Many of my patients felt that they had barely lived their lives when I showed up, ostensibly to help them "die with dignity."

Death may be humanity's great equalizer, but the inequalities suffered in life – leading to a shorter life expectancy – become inequalities in the experience of dying as well.

When I began my career, I had na├»vely assumed that, if time were short, who wouldn't prefer the familiarity of home and palliative medicine's focus on quality of life to the chaotic mess of the hospital? But I've learned that even when my patients accept hospice services, the proverbial "good death at home" is often out of their reach. Fully experiencing the benefits of home hospice requires resources: involved, dedicated family members. Money to afford caregivers, particularly in the absence of involved family members. A neighborhood whose local pharmacy actually stocks opiate medications for severe pain. Insurance that covers stays in nursing homes so that family members can simply be family members instead of caretakers.

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You Are Stronger Than You (and Your Therapist) Think - The New York Times

I'm a psychiatrist who has spent most of the past 30 years treating patients with moderate to severe mental illness. But I've also administered care for the Massachusetts Department of Mental Health, Harvard Medical School and several insurance companies, and so I'm often asked for advice by colleagues who feel their patients need more help than an insurer is willing to pay for. In addition to offering technical advice, I often become, in essence, the therapists' therapist, at least in terms of their treatment choices. And sometimes those interactions are as intense as therapy itself. 

Recently, one such colleague was desperately worried about a patient whom he had treated weekly for years after a serious suicide attempt. He felt that they had made great, gradual progress, both through medication and talk therapy. Because she was a victim of childhood sexual abuse, however, there was lingering vulnerability. Now her insurer had decided that she did not need more than 12 sessions a year, and this had thrown her into a panic. It appeared to the therapist that all the years of progress were unraveling before his eyes. He felt that weekly sessions were necessary to prevent her from relapsing, as did she, but he couldn't persuade the insurance company, and now his panic level was matching hers.

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