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For the Very Old, a Dose of ‘Slow Medicine’
By Abigail Zuger, the New York Times
February 26, 2008
Embracing "Slow Medicine," the Compassionate Approach to Caring for Your Aging Loved Ones. By Dennis McCullough, M.D. HarperCollins. 263 pages. $25.95
It was two decades ago that a group of culinary mavericks took a giant step backward down the evolutionary trail with the “slow food” movement. Instead of fast food produced by the assembly lines of giant consortiums, they championed products of small-scale agriculture — time-consuming to prepare, beautiful to behold, very good for you.
Now (and, some might add, at last) doctors are following suit, rejecting the assembly line of modern medical care for older, gentler options. The substituted menu is not for all patients — at least not yet. For the very elderly, however, most agree the usual tough love of modern medicine in all its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps.
In its place, doctors like Dennis McCullough, a family physician and geriatrician at Dartmouth Medical School, suggest “slow medicine” — as he puts it, “a family-centered, less expensive way.”
This medicine is specifically not intended to save lives or to restore youthful vigor, but to ease the inevitable irreversible decline of the very old.
Dr. McCullough directs his book to the children of elderly parents, and he pegs it to the story of his mother. She evolved from a vital, healthy 85-year-old retiree to a feeble 92-year-old dying in hospice care, not from any particular disease so much as the aggressive frailty common among the oldest of old people.
His bottom line is this: It is up to friends and relatives to rescue the elderly from standard medical care. And slow medicine, like slow food, involves a lot of hard work. Readers who sign on will acquire a staggering list of tasks to perform, some of which may be just as tiring and tear-producing as chopping onions.
First, while the aging parent is still vital and lively, children must not fool themselves that this happy situation will last forever. This is the time, Dr. McCullough suggests, to reinsert themselves back into the parent’s life, to show up at doctor visits and to raise unpleasant topics like advance directives and health proxies.
After few more years, it is time to address the “Should you still drive?” and “Can you still manage at home?” issues, and to help create routines that compensate for a slipping memory and slightly wobbly balance.
Medical crises will inevitably arise; the child must be vigilant for a hospital’s bad habits when caring for elderly patients. An “advocacy team” of friends and relatives should be mustered to help protect the hospitalized parent; a wider “circle of concern” should be tapped for moral support.
Still down the road is the complex world of rehabilitation, either home-based or institutional, and the even more complex spectrum of available nursing options for the slightly impaired, the seriously impaired and those near death.
All the while, medical care for the parent should favor the tried and true over the high tech. For instance, Dr. McCullough points out that instead of a yearly mammogram, a manual breast exam may suffice for the very old, and home tests for blood in the stool may replace the draining routine of a colonoscopy.
The parent’s doctors should be nudged to justify flashy but exhausting diagnostic tests, and to constantly re-evaluate medication regimens. The high-blood-pressure pills that are life-saving at 75 may cause problems at 95, and paid companionship or a roster of visitors may prove to be antidepressants at least as effective as any drug.
The pace of care should be slowed to a crawl. For doctors, that means starting medications at low doses and increasing them gradually. For children, that means learning not to panic and yell for an ambulance on every bad day. And for a good overall picture of a parent’s condition, a child is well advised to ignore the usual medical and nursing jargon and to focus instead on the sound of the parent’s own voice. “No one,” Dr. McCullough says, “can be a bigger expert on a parent’s voice than a former teenager trained in the same household.”
Some standard self-help muzziness creeps around the edges of this book, with reflections on the value of scrapbooks to preserve family memories and admonitions that “it is always the right time to say ‘thank you’ and ‘I love you.’ ” Dr. McCullough’s decision to call each stage of old age a “station” (as in “The Station of Crisis,” “The Station of Decline” and “The Station of Prelude to Dying”) may be a little too religious for some and far too reminiscent for others of the food stations at large catered events.
Instead, he might have steeled the book’s spine with a few hard-headed tips for those who would valiantly try to slow the twin Mack trucks of the modern doctor and the modern hospital. How should relatives go about applying the brakes to their fast doctors without alienating them or earning for themselves the label of troublemaker? Dr. McCullough, by his own report, works in something of a paradise when it comes to geriatric care, but in many medical venues the phrase “slow down” is an obscenity.
Still, he has written a valuable book, chilling and comforting in equal measure. A similar book directed at fast doctors, fast hospital administrators and fast insurers might be the next welcome stride backward down the path.
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