Bucket list

Preparing to "kick the bucket"

At this month’s Jewish Community Center of San Francisco’s 2^nd Annual Embracing the Journey End of Life Resource Fair, attendees were presented with a bucket list kit—complete with bucket, pencil, mini-composition book and instructions to answer: What do you want to do before you “kick the bucket”?

I thought been there, done that.  Long before the Hollywood film The Bucket List (2007), I compiled a list of places to visit and pursued them all.  While I enjoyed the anonymity and stimulation from exposure to different cultural experiences during my world travels, however ephemeral, I felt world-weary after I became eligible to join Travelers Century Club.  Like Thomas Jefferson noted, travel makes one “wiser, but less happy.”  So I reduced my carbon footprint by staying home, content to put down roots while returning to my childhood pastime of gardening (being with nature).   

“…chasing bucket-list thrills ignores a deep psychological truth: You don’t need to make yourself happy in old age.  We get happier naturally as we grow older… The increased happiness doesn’t come through doing but simply through being.  It is the natural result of lower expectations and ambition, less emotional volatility, increased gratitude and acceptance and enhanced problem-solving skills.

In fact, the need for a bucket list goes against our deepest instincts as we age. Older brains are less influenced by novelty-seeking and more by conscientiousness; they are less impetuous and more emotionally stable.” 

– Marc E. Agronin, MD, geriatric psychiatrist, It's Time to Rethink the Bucket-List Retirement 

Stan Goldberg, cancer survivor, hospice volunteer and author of Lessons for the Living: Stories of Forgiveness, Gratitude, and Courage at the End of Life, presented, One Day to Live: What Would You Say and Do?

1. focus on journey – makes it easier to accept losses and prepare for death; start with one simple, enjoyable activity
2. ask for forgiveness – makes you more peaceful
3. offer forgiveness – begins healing
4. understand what/when you can’t forgive – work towards understanding
5. let go of what you can’t change
6. offer thanks for kindness shown – change relationship
7. complete unfinished business
8. create legacy – make a difference 

Therapeutic humor expert Allen Klein provided comic relief in his presentation, Seeing Demise Thru Humorous Eyes: How Cartoonists, Comedians and Cinematographers Help Us See Death as Less of a Grave Matter.   My favorites were clips from Woody Allen films like Hannah and Her Sisters (life affirmation after attempted suicide) and Love & Death (dance with death).

End of Life (EOL) Options (ways to "kick the bucket")

Matt Whitaker, Multi-State Implementation Manager at Compassion & Choices, provided an overview of authorized EOL options:

1. refuse treatment
2. discontinue treatment
3. hospice – “gold standard” for last 6 mos. covered by Medicare, but average utilization only 20 days
4. VSED (Voluntarily Stop Eating & Drinking) – death by dehydration
5. palliative sedation – induce coma
6. aid in dying – legal in 5 states, OR (since 1997), WA (2008), MT (2009), CA (2016) and CO (2017)

California’s End of Life Option Act requires self-ingestion of a lethal dose of 100 capsules of Seconal, produced by Valeant Pharmaceutical, at a cost of $4,000; in California, only 80% of private insurers and Medi-Cal cover this cost.  A 1997 federal law prohibits use of federal monies (Medicare, VA) to cover aid in dying costs. 

JFCS Seniors at Home hosted End of Life Option Act: Effects on our Practice panel presentation:

• Linda Blum, GNP, Palliative Care Coordinator at California Pacific Medical Center: shared two cases when patients were not able to exercise EOL Option due to short time frame of patient with untreatable gastrointestinal bleeding who died in hospice at home before he was able to manage 2 requests to doctor, and another patient with ALS who was not able to self-administer aid-in-dying drug; in both cases, it was “care as usual, the old way.”
• Maryellen Collamore, ASW, Oncology Clinical Social Worker at UCSF: talked about her role to provide educational materials on EOL Option and to conduct psychosocial assessment of patient (motivation for inquiry, understanding of diagnosis, social supports, defining quality of life, perception of dying process, exploring belief systems, etc.); patient also must obtain mental health evaluation by psychiatrist; easier to find consulting MD than to find MD who will actually prescribe aid-in-dying drug; patient’s initial inquiry opens door to conversation, and most patients go to hospice.
• Lael Duncan, MD, Medical Director at Coalition for Compassionate Care California: opined that access remains an issue, given the length of the process (patient makes 2 oral requests > 15 days apart, patient attestation 48 hours prior to ingestion) and few participating providers. She described lethal prescriptions—traditional high dose barbiturate (100 capsules of Seconal used in Oregon) dissolved in 4 oz. water; cocktail mixtures (opiates, benzos, cardiac meds); complications can arise if patient has difficulty swallowing, digestive issues, insufficient absorption; time to death depends on underlying disease process and patient’s physiology, but usually deep coma within 10-15 min. after ingestion.
• Redwing Keyssar, RN, Director of Palliative Care at JFCS Seniors at Home: shared two cases of patients who changed their minds about EOL due to different outlook and changed circumstances because pain and symptoms were better managed. 

Lonny Shavelson, MD, started Bay Area End of Life Options in Berkeley, to consult with physicians and patients who are deciding whether to participate in EOL Options Act. He sees writing the lethal prescription to a terminally ill patient as the last resort only after considering alternatives (hospice and palliative care approaches).  

Documenting life

At Rhoda Goldman Plaza, Gloria Hollander Lyon, who survived seven concentration camps during the Holocaust, read excerpts from her memoir, Mommy, What’s that Number on Your Arm? A-6374: failing Dr. Mengele’s inspection and then escaping the gas chamber by jumping off a truck at age 14; later living with a foster family in Sweden after liberation when she noticed she lost her sense of smell – perhaps her body’s defense mechanism to protect herself from the horrific stench of bodies burning in the gas chambers and crematoria; and then returning to visit Auschwitz in 1991 when she finally regained her sense of smell after 47 years. 

Addressing an intergenerational audience that included her son, Lyon said her father told her what is important: do not cry over what is lost if you have freedom for continued life, let it rest and start all over; those who survive are eager to tell the world that it’s worth surviving regardless of loss. 

Lisa Kokin’s Inventory, exhibited at From Generation to Generation: Inherited Memory and Contemporary Art at Contemporary Jewish Museum, is composed of over 1,000 pieces of objects representing the lives of those who endured the Holocaust.  Inventory was created in 1997 after the artist, whose own Jewish family left Europe before Hitler’s rise, visited Buchenwald concentration camp and confronted the piles of objects left behind.

At this month’s meeting of San Francisco Task Force on Hoarding, Carolyn Rodriguez, MD, PhD, Director of Stanford Hoarding Disorders Research Program, talked about her research combining Buried in Treasures (BIT) workshop support group with one-to-one home de-cluttering.  She viewed hoarders as “enthusiastic collectors” and talked about elevating ordinary objects into art by Marcel Duchamp’s Readymades and Andy Warhol’s Time Capsules.  She mentioned artist Song Dong’s Waste Not installation of over 10,000 everyday objects collected by his mother in their Beijing home over five decades that reflects on culture of frugality; in persuading his mother to make art out of her possessions, the artist showed respect while also improving the quality of home life by de-cluttering – more creative than the KonMari method! 

As in Roz Chast’s Can’t We Talk About Something More Pleasant? discussing hoarding and even the inevitable like end of life can be uncomfortable for some.  Yet, the wisdom of Ecclesiastes chapter 3 reminds us: “there is a time for everything … a time to be born and a time to die … all come from dust, and to dust all return.”

With Howard Levy, Executive Director at Legal Assistance to the Elderly (LAE) for 28 years until his retirement today, all discussions are possible! (Though professionally, Howard is probably not as candid as his high school classmate Pepper Schwartz, AARP’s Sex and Relationship Expert and author of the sizzling erotic memoir, Prime: Adventures and Advice on Sex, Love and the Sensual Years.)  At weekly case acceptance meetings deftly facilitated by Howard, all staff and volunteers present contributed to the lively, often passionate, discussions for each client intake after hearing the facts.  Occasionally tired of the faux (steamed, not authentically boiled) bagels brought in by Howard, staff and volunteers turned the weekly meetings into potluck affairs.  Howard and the mostly senior staff at LAE remind me of The Supremely Old, Supremely Sharp, Supreme Court, with their wit and crystallized intelligence, which gets better with age. 

Inspired to create my own art, here’s collage of Howard's greatest hits at LAE’s office and fundraising events!

Shut-ins

In contrast to my mostly homebound senior clients, I’m usually out and about so I’ve often considered taking a 30-day challenge to live like a shut-in so I could experience life like my clients.  As an introvert, I am inspired by shut-in clients who engage in creative arts like writing and publishing poetry, painting and selling artworks online, composing and performing music, etc.     

The Shut-Ins perform at fundraiser for Legal Assistance to the Elderly (LAE).  

LAE staff attorneys – Judy Hitchcock (elder abuse prevention; also Spanish bilingual), Christine Lau (public benefits; also Cantonese bilingual), Tom Drohan (housing; also bass player with The Shut-Ins) – have been with LAE for about 25 years each!  Paralegal Christy Nieves brought age diversity (and Spanish bilingual skills) after Bessie (who joined LAE in 1980 shortly after its founding) retired last year.  

Volunteer receptionist Tom Tallman (sandwiched between friend Richard and LAE Director Howard Levy, in photo above) has been with LAE for more than 25 years! 

Howard presented long-time LAE volunteer paralegal Sandra Fenix (Portuguese bilingual) with Volunteer Award. 

Howard announced his retirement by year-end after 28 years as LAE’s Executive Director.  Howard’s legacy is his role in fostering employee and volunteer retention (aging in workplace!), which seems remarkable for a non-profit serving older adults in San Francisco.  (Staff retention also helped by union membership in National Organization of Legal Services Workers.) 

LAE Board (not bored) member and journalist Tim Redmond noted that 14% of eviction defense cases in San Francisco are represented by LAE, winning each case to promote aging in place!  Woo-hoo! 

Get up and dance to music of The Shut-Ins!

Mental health 

Department of Aging & Adult Services (DAAS) Education Coordinator Rick Appleby introduced presenters at DAAS Community Training on Mental Health in Older Adults.  None of the presenters were psychiatrists, but it was refreshing to hear two geriatricians take a holistic (mind+body) approach rather than focus only on internal medicine diseases of older adults. 

Pei Chen, MD, UCSF Division of Geriatrics, presented on Depression, Suicide and Loneliness.  The risk factors for late on-set depression and loneliness seemed to describe my shut-in clients:

• Female
• Social isolation or low contact with friends or low quality relationships
• Widowed, divorced, separated marital status
• Lower socioeconomic class
• Comorbid medical conditions or worsening physical health

Dr. Chen shared screening tools for depression (PHQ-9), suicidality (P4), and loneliness (De Jong Gierveld 6-item).  Her recommendations: ask about mood/loneliness, be present and encourage interactions, connect with community resources.

While my shut-in clients seem receptive to contacting Friendship Line or friendly visitor programs, they are sometimes reluctant to seek services of mental health professionals due to stigma. 

Anna Chodos, MD, UCSF Division of Geriatrics, presented on Substance Abuse, a cohort issue with higher lifetime prevalence among baby boomers age 60-64. She also noted that 25% of older adults use psycho-active prescription drugs with potential for misuse/abuse:

• Opiates: morphine, oxycodone, methadone; 40-50% older adults in chronic pain
• Benzodiazepine: lorazepam, diazepam, etc.; avoid in older adults as these may cause decreased attention, memory, cognitive function, motor coordination lead to increased risk of falls/car crashes
• Medical marijuana: controversial (risk/benefit not clear); used for neuropathy, glaucoma, pain, anxiety

Screening for substance use disorders include TWEAK for alcohol use, and DAST-10 for other substance use.

Tobacco is the most common substance used by my clients.  As much as I want to support aging in place, there have been days when I’d come home smelling like an ashtray after home visits with clients who smoked like chimneys, and I’d think I’d be better off in a non-smoking institution like a nursing home!

Sonya Maeck, LCSW, Clinical Administrator and Program Director at Jewish Home, discussed her facility’s 12-bed acute geriatric psychiatry hospital that exclusively serves older adults who require short-term treatment (average 18-day stay) for psychiatric conditions like anxiety, depression, suicidal thoughts, etc.  Its staff has specialized training in the unique medical and psychiatric needs of older adults to evaluate physical conditions (e.g., infection) that can be underlying factors in mental disorders; after successful treatment, the goal is for the senior to return home.

Encourage interaction

My work with shut-ins is rewarding with opportunities to make a difference and the mutual appreciation for home visits.  While I wish I had more time with clients, I have a fairly tight schedule of 5 to 6 home visits per day plus travel time.  I often politely redirect clients who use questions to seque into long stories.  (See The Onion video report, “Census Visits Providing Shut-Ins Once-A-Decade Chance For Human Interaction,” featuring 87-year-old Helen DeAngelis who gives tips for trapping a census worker in your home for as long as possible.) 

For example, when I asked one client about her mobility, she replied that she used a cane to ambulate, and then she proceeded to recount her delightful story about getting the carpet in her studio apartment shampooed, which required her to leave home for 6 hours, so she took this opportunity to explore her neighborhood, which included visiting library to get a library card, then went to the movie theatre, etc.  Being out and about improved her disposition.

One way to reduce isolation of shut-ins is to fix broken doorbells, especially those who live in houses with outer gates preceding front doors so visitors need to ring doorbell or telephone: ding-dong-ding, how else can Jehovah’s Witnesses go door-to-door and reach isolated seniors who might welcome free home Bible studies?

Advance care planning 

San Francisco Village and Institute on Aging (IOA) hosted Talk to Me: Conversations that Matter about advance care planning and end-of-life options. IOA’s Patrick Arbore was a no-show due to illness, so SF Village Executive Director Kate Hoepke assumed role as moderator, opening up discussion by asking panelists what are the results of having these conversations?

• Sarah Hooper, Executive Director of the UCSF/UC Hastings Consortium on Law, Science & Health Policy, talked about how the process of documenting one’s legacy (in the form of advance health care directives, power of attorney for finance, wills, etc.) is empowering because law students care to ask and listen to clients about their goals and wishes, which are given the force of law—yet emphasizing the conversations are more important than the forms.

• Eric Widera, Clinician-Educator at UCSF Geriatrics, said “ditto” adding though it’s hard to predict future situations, conversations focus on what are important values—some people are known to appoint their bartender, who is someone they trust, they can have conversation and who is available to serve.

• Stefanie Elkins, California Medical Outreach Manager at Compassion & Choices, discussed California End of Life Option Act, which became effective June 9, 2016, authorizing medical aid in dying.

Because I have shut-in clients who cycle in and out of hospice care, I wonder about California End of Life Option Act applying to terminally ill adults with a “prognosis of six months or less to live” when it is difficult to predict when someone will die.