better with age

Saturday, June 30, 2018

Lifelong learning

“Regarding people as having lives of equal worth means recognizing each as having a common core of humanity. Without being open to their humanity, it is impossible to provide good care to people…To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond…

We are in a dangerous moment because every kind of curiosity is under attack…This is what happens when the abiding emotions have become anger and fear. Underneath that anger and fear are often legitimate feelings of being ignored and unheard—a sense, for many, that others don’t care what it’s like in their shoes. So why offer curiosity to anyone else?

Once we lose the desire to understand—to be surprised, to listen and bear witness—we lose our humanity. Among the most important capacities that you take with you today is your curiosity. You must guard it, for curiosity is the beginning of empathy. When others say that someone is evil or crazy, or even a hero or an angel, they are usually trying to shut off curiosity. Don’t let them. We are all capable of heroic and of evil things. No one and nothing that you encounter in your life and career will be simply heroic or evil. Virtue is a capacity. It can always be lost or gained. That potential is why all of our lives are of equal worth…”

—Atul Gawande, MD, MPH, “Curiosity and What Equality Really Means,” The New Yorker (June 2, 2018)

In this month’s National Resource Center for Engaging Older Adults webinar,

engAGED: Increasing Social Engagement through Lifelong Learning, National Resource Center for Osher Lifelong Learning Institutes (OLLI) presented OLLI members' top interest topics, in this order: history, fine arts, current affairs, literature, religion and philosophy, and health and wellness. With my insatiable curiosity (like Albert Einstein, who said, “I have no special talent. I am only passionately curious”), my idea of recreation is leisurely lifelong learning. As I go about my existence as a lifelong learner-gerontologist, I am always scouting for activity programming ideas to bring to older adults at their residential community or scheduled outings.

Fine arts

Sixty Plus—OLLI at SFSU’s Theater Showcase previewed upcoming productions from local theater companies:

· Golden Thread Productions: Founding Artistic Director and SFSU alumna Torange Yaghiazarian introduced Melis Aker’s Field, Awakening with its main character reuniting with friends from high school on the eve of the 2016 attempted military coup in Turkey. Liked line, “You get to do what you wake up for,” but trigger alert for lot of “f-ck” word in script.

· San Francisco Playhouse: Patron Services Manager Tiiu Rebane sang title song from Stephen Sondheim’s Saturday in the Park with George and “Maybe this Time” from Cabaret. She likened theater participation to an “empathy gym” to practice compassion.

· Bay Area Musicals: Founder and Artistic Director Matthew McCoy discussed the role of theater to make us think, reflect and feel. Juan Castro and Loreigna Sinclair sang “In a Place of Miracles” and “God Help the Outcasts” from Disney’s Hunchback of Notre Dame, exploring themes of disability, immigration, and discrimination.

(SFSU’s College of Extended Learning offers Elder College for people age 50+ who pay $55 per semester to sit in any regular university course on a space available basis with instructor approval. City College of San Francisco's Older Adults Program offers free, non-credit courses designed for people age 55+, which are open to all; its Free City Program recently received funding for two years to offer free summer courses.)

Outing to 42^nd Annual SF Free Folk Festival’s Jug Band Jam, with Christopher Richard, Miller Wise and Wayne Hagen, inviting folks of all ages to bring their own instruments to join in on jug-band classics, with songbooks provided.

Director/Choreographer Bruce Bierman and Musical Director Ellen Robinson brought along Stagebridge participants to older adult communities for live performances of A Chorus Line.

In this adaptation of A Chorus Line, Stagebridge participants audition by introducing themselves, sharing events that shaped their lives and decisions to become dancers. Of the ten in this ensemble, only one was male.

History/Literature

Laura Bock, author of Red Diaper Daughter: Three Generations of Rebels and Revolutionaries (2017), and friend Sally Goldin, at this lively book reading/discussion party. As an only child, Laura wanted to pass on her family legacy by publishing her memoir at age 70, sharing stories of her “red” grandparents who sought to overthrow the Russian czar before immigrating to the U.S., her anarchist/communist parents who were labor organizers, and her own life as “red diaper daughter” carrying the tradition of activism (as she left for college, her parents advised her, “Now, make sure you get arrested for something political, and not just for drunkenness!”) through the 1960s civil rights and anti-war movements, 1970s women’s liberation and disability rights, 1980s fat and LGBT liberation, etc. A self-described "groupie," Laura has been a model for community building and interdependence—running a bed and breakfast business in her family home; co-founding Fat Lip Readers Theater; joining/starting support groups for fat women, coming-out, disabled lesbian, Jewish women’s study, hard-of-hearing, old lesbian grief and loss, break-up, etc. Red Diaper Daughter is accessible via Bookshare for people to read with eyes, ears or fingers.

Health & wellness

Brain fitness

June is Alzheimer’s and Brain Awareness Month, and Jewish Community Center of SF (JCCSF) hosted its 2^nd Annual Brain Fitness Forum. Some highlights:

Serggio Lanata, MD, of UCSF presented Alzheimer’s Disease Prevention: What’s the Evidence.

Caitlin Moore, PhD, founder of California Brain Health Center, presented Lifestyle and Brain Aging: A Multimodal Approach for Optimal Brain Health.

· Exercise: anything better than nothing; recommend 30 minutes moderate intensity 5x/week (can’t sing, but can comfortably talk, during activity)

· Diet: Mediterranean (fruits, green veg, healthy fats—nuts, seeds, avocado, dairy and poultry once/week, wine in moderation), DASH (more grains, few times meat, fewer fats); best diet is one can stick to, fit into lifestyle (drink greens “quick way to choke down,” whole fruits as dessert, healthy fats like nuts and olive oil, whole grains, limit sugar intake, stay hydrated throughout day)

· Sleep: 6-8 hours, but more is not better; schedule bed time and wake time; no digital screen 30 minutes before bedtime to give brain break from stimulation; if not sleep within 20 minutes, do something mindless; address issues that interfere with sleep—mood/worry, frequent bathroom breaks, pain (treat perception, avoid “PM” meds)

· Habits: quit smoking; control heart risk factors

· Hearing loss: tied to memory loss, as part of brain responsible for hearing next to hippocampus (memory), tend to isolate due to frustration in social situations; Medicare covers hearing evaluation; wear hearing aids

· Stay engaged: participate in mentally and socially stimulating activities to maintain cognitive reserve (amount of brain damage before show symptoms, influenced by high education/IQ/complex occupation use brain), find activities that bring passion involving emotion/spirit—don’t do crosswords if you hate to; challenge real life—walk dog, memoir writing, gardening, volunteering, find purpose; avoid loneliness by being proactive like organize outings

· Compensatory strategies for memory and attention: minimize distractions, organize/clear clutter; buy pillbox to avoid risk of missing medication dose; use calendar to immediately record appointments, prioritize and check off to-do list, store frequently used items like eyeglasses and keys in memory table; keep positive mindset; seek help from family, friends, therapist to treat anxiety and depressed mood

· Subjective memory loss: talk to PCP about concerns; early diagnosis is opportunity to treat symptoms with medication and lifestyle modification, decide what to do with remaining years

· Marijuana: causes memory problems, especially avoid after age 60

JCCSF Lifelong Learning Programs Manager Shiva Schulz introduced Just Do It: Exercising Your Way to Brain Health presenters Larriana Williams, CCC-SLP from ONR, Inc. and Christine Roppo Soares, LCSW from San Francisco Campus for Jewish Living.

· Plasticity: brain’s ability to change in response to experience continues throughout lifespan, remap brain circuits especially after stroke (use non-dominant to create new pathways)

· Enriched environments

· Power naps help consolidate new information

· Focused concentration most important, attention equivalent to endurance

· Multi-tasking is myth: tasks are done sequentially, not concurrently

· Cognitive reserve: challenge brain to learn new

· Puzzles and games may improve working memory, not improve brain function

· Aerobic activity increases blood flow, oxygenation, neural pathways

· Just do it: mindful movement (meditation, prayer), breathe, engage, relax, keep healthy brain vision statement

Meet the Author Francine Toder signing her book The Vintage Years (2013), with husband Joe at her side, as she chats with psychologist Beth Krackov.

Game room featured tables with Scrabble (70 years old!), Scattergories, Taboo, and jigsaw puzzle.

Video Center included Citizen Brain: The Empathy Circuit with Josh Kornbluth

about how empathy works in the brain with the potential to save the world because empathy allows us to get along with one another. Empathy is when you imagine what it might feel like to be in someone else’s shoes. UCSF researcher Virginia Sturm, PhD, called empathy “the most important thing.” UCSF neuroscientist Bruce Miller, MD, discovered that people with frontotemporal dementia (FTD) lose their empathy, so they are often alone and isolated. When empathy circuit is broken, we connect less especially with people outside our group; due to divisions, we cannot work to solve problems. In contrast, people who care about and connect to others can unite humanity. Our empathy circuits can be strengthened—take a deep breath, imagine why and how the other person is feeling …

Forum concluded with a screening of the 95-minute documentary, In Search of Memory: The Neuroscientist Eric Kandel (2009). Austrian-born American neuroscientist Kandel’s trauma as an Austrian Jew who fled from the Nazis at age nine contributed to his curiosity about the contradictions of human behavior and research that won the 2000 Nobel Prize in Medicine for discovering the central role of synapses in memory and learning.
The film also showed Passover Seder with his family discussing Nobel Prize-winning physicist Isidore Isaac Rabi: when asked why he became a scientist, he replied, “My mother made me a scientist without ever knowing it. Every other child would come back from school and be asked, ‘What did you learn today?’ But my mother used to say, ‘Izzy, did you ask a good question today?’ That made the difference. Asking good questions made me into a scientist.”

Shout out to the many awesome experts who meet older adults where they are (in their residential communities) to engage in the lively exchange of ideas and information to promote health and well-being.

Serggio Lanata, MD, of UCSF Memory and Aging Center, presented on Brain Health, including ways to reduce risk of Alzheimer’s disease and related dementias:

· Modifiable medical factors: hypertension, hyperlipidemia, type 2 diabetes, smoking, untreated depression.

· Modifiable lifestyle factors: cognitive stimulation (diversify mental activities by exposure to new/different stimuli; engage different regions of brain—e.g., occipital lobe in back of brain processes visual information, so engage it by looking at things that are stimulating like art; temporal lobes at ear level associated with memory and hearing interpretation, so music stimulates emotion and better if you can play instrument or sing); physical activity (older adults who maintain physically active lifestyles reduce their risk of serious illness by up to 50%, compared to sedentary older adults; chart shows muscle mass and strength peak at age 30, and how an active person can minimize muscle loss and remain above disability threshold into old age); nutrition (check vitamin B12 and D levels); social engagement (lessen loneliness by connecting with other people, empathy helps); and adequate sleep.

Dr. Lanata gave way more than the usual 15-minute doctor visit, ably answering questions based on his training in biological sciences, food science and nutrition, physiology, complementary and alternative medicine, and neurology.

Hearing

Jessie Johnson, Clinical Practice Manager from Hearing and Speech Center, presented on Cognition and Hearing: Hearing loss, if untreated, puts people at risk for dementia and social isolation. Hearing aids and aural rehabilitation are evidence-based treatment options for improving hearing (sense) and listening (skill).

Jessie also presented on Assistive Listening Devices and Hearing Related Apps (tinnitus, sound level meter, aural rehab, communication).

California Phones Outreach Specialist Casey Kho, MSW, presented demonstration of specialized phones to make it easier to hear, dial and call. These phones, as well as cellphone amplifiers, are available at no cost through California Telephone Access Program, to California residents who have difficulty using a standard telephone.

End-of-life (EOL) starring medical doctors

Is the brain, which stores memory, overrated? According to Dr. Kandel, “Memory is everything. Without it we are nothing.” A related view holds that “brain death means really dead” because without brain function, the body eventually shuts down unless there is medical intervention.

This month I attended two short Netflix documentary screenings about EOL care focused on palliative care doctors in San Francisco Bay Area, and attended a presentation on advance care planning by a local patient advocate MD.

JFCS’ Seniors At Home's Palliative Care Program hosted a screening of Extremis (2016), the Oscar and Emmy-nominated short (24 minutes) documentary about end-of-life decision making in an intensive care unit (ICU) at Highland Hospital in Oakland. Extremis features Jessica Zitter, MD, MPH, who practices ICU and palliative care medicine, treating patients with no hope of getting better. She told us that she got into medicine wanting to save lives, her medical training taught her to see patients as a collection of organs like fixing broken machines, and hospital hierarchy was like the military lacking reflection and humanism. As a result, the default is to prolong life, without considering quality of that life. She discussed need to change this culture, after she learned to be reflective, collaborative and supportive from a nurse, chaplain and social worker in the palliative care consult team. She said humility and courage is needed to say what will happen to patients and families, providing realistic information including breaking bad news compassionately and discussing option to “pass naturally” when medicine has no cure. Dr. Zitter is also author of Extreme Measures: Finding a Better Path to the End of Life (2017).

Ungerleider Palliative Care Lecture Series at California Pacific Medical Center (CPMC) hosted a screening of End Game (2018), a short (40 minutes) documentary film starring UCSF palliative care doctors, Steven Pantilat, MD, and BJ Miller, MD (also former Executive Director of Zen Hospice Project’s six-bed Guest House, which recently closed). My favorite soundbites:

“It’s healthy people who think about how they want to die, and sick people who think about how they want to live.” – Dr. Pantilat

“There is nothing inherently medical about dying. It’s much larger than medicine. It’s purely human.”—Dr. Miller

This screening was followed by a CPMC bioethicist moderating a panel discussion with Dr. Pantilat (Founding Director of UCSF Palliative Care), Bridget Sumser (UCSF palliative care clinical social worker), and Shoshana Ungerleider, MD (CPMC hospice and palliative care physician who also produced End Game and funded Extremis). As Dr. Zitter discovered, there is more to medicine than performing procedures to prolong life; palliative care is the art and science of healing that integrates the medical and social models of care, so honest conversations can take place enabling patients (or their proxies) to make informed decisions about their EOL care. (Check out, “Is hospice on your bucket list?” by Kimberly Baumgarten, RN, FCN.) In a nutshell, know what matters in your life and communicate with your loved ones and doctor.

At North Beach Library, NEXT Village SF hosted a presentation on Patient Advocacy, Difficult Medical Decisions, Advance Care Planning with Jennifer Brokaw, MD. Dr. Brokaw worked with NEXT Village co-founder Jonee Levy during her 1-1/2 year struggle with stage 4 lung cancer through Jonee’s death in her home in February.

During nearly 15 years of practicing emergency medicine, Dr. Brokaw noticed patients were older and sicker yet she was asked to “do everything” because patients did not understand the course of their disease. With Lael Duncan, MD (now Medical Director at Coalition for Compassionate Care), Dr. Brokaw started Good Medicine Consult & Advocacy Services in 2008--“5-1/2 years ahead of time,” before Medicare created billing code for EOL discussions.

Dr. Brokaw led an exercise to create our own advance care plan on 3” x 5” index card.

Side 1:

· Appoint health care agent (HCA) who knows you, are in touch frequently with open line of communication, knows and honors your values and beliefs, ideal if live nearby, and comfortable in medical setting to ask difficult questions.

· Goals: address how you want to be until you die

· Values: priorities

· Beliefs: spiritual statement that give survivors comfort

Side 2

· Finances: assets to pay for LTC

· Fears: what experience that you do not want to repeat

· Funeral: memorial, donate body to UCSF

Next steps: You and 2 witnesses sign card. Call HCA to talk about your wishes. Notify Primary Care Physician: Medicare/Medicaid will pay for advance health care discussions ($170 for 1^st discussion, $80 for 2^nd discussion with HCA)

Thursday, May 31, 2018

Older Americans Month: Engage at Every Age

The theme of this year’s Older Americans Month, Engage at Every Age, was announced on the Administration for Community Living website:

“… you are never too old (or too young) to take part in activities that can enrich your physical, mental and emotional well-being and celebrates the many ways older adults make a difference in our communities.

Participating in activities that promote mental and physical wellness, offering your wisdom and experience to the next generation, seeking the mentorship of someone with more life experience than you—those are just a few examples of what being engaged can mean.”

The Vintage Years: engagement in fine arts

Older age provides advantages to engage in the fine arts, according to Francine Toder, PhD, author of The Vintage Years: Finding Your Inner Artist (Writer, Musician, Visual Artist) After Sixty (2013). In her presentation, Stimulating the Brain and Psyche: Benefits of Finding/Practicing a Fine Art Form After Sixty, Francine viewed the vintage years as a reward for decades of hard work, allowing more time and focus for fresh perceptions and new exploration. Following the multi-tasking overload of our midlife years, our vintage years are characterized by a slower pace, steadier hormones, calmness/more emotional stability, laser sharp focus, more time flexibility, fewer demands on time, and the sense of “if not now, then when?” (like the Tracy Chapman song!)

Francine’s book opens with Chapter 1, “The Time of Your Life: Now or Never,” about 89-year-old Matty Kahn, who had no musical knowledge before volunteering for Never2Late project, to begin learning to play the cello in a month’s time. Matty succeeded after meeting 8 hours a day, one day a week, for one month, with cello teacher Bianca Kovic, who documented this experience in a 15-minute film, Virtuoso: It’s Never Too Late to Learn (2008). Francine shared her own similar experience of taking up cello playing, though she was 20 years younger than Matty, setting aside self-doubt by reasoning, “If she (Matty) can do it, so can I!” However, instead of cramming, Francine explained that older adults learn best with spaced learning: short daily practice sessions over a long period of time, to reinforce short-term memory so that it can convert to long-term memory.

Francine noted that “our mature brain thrives on the very things that are pleasurable and add zest to life: creativity and physical, social and mental activity.” Specifically, Francine’s research found that after midlife, our brain’s right and left hemispheres become better integrated, more interdependent and more functionally intertwined; patterning that facilitates problem-solving in mature brains are based on generic memories that accumulate with age. The fine arts also offer an abundance of the "magical triad"—novelty/newness, complexity, and problem-solving—for our mature brains to continue developing, according to brain plasticity research. In addition to supporting brain health, Francine shared the numerous psychosocial benefits of taking up the fine arts: greater life satisfaction, increased passion, enhanced sense of well-being, increased ability to focus sharply, and an expanded social community.

Francine also practices the fine art of writing daily; her next book is tentatively entitled, Inward Traveler: 51 Ways to Explore the World More Mindfully.

Wonder: engagement in musical theater

Older adults from Stagebridge Theater were fully engaged in this production of Wonder, “a theatrical curiosity on the impermanence of self” adapted from Alice’s Adventures in Wonderland by Lewis Carroll. In this “musical fantasia on dementia,” the audience follows Alice, a retired math teacher who is newly admitted to a Memory Care unit.

Furious at losing her logical mind, Alice can’t seem to adapt to her new surroundings … after swallowing too many of her meds, Alice is taken on a hallucinatory trip into her imagination revealing many different sides of herself (“I’m not the same person—who am I?”). Alice is played by an actor dressed like “Tootsie” and the cast starts dancing to “White Rabbit” sung by Grace Slick.

Audience joined Stagebridge cast on stage, dancing in finale of Wonder. All four shows of Wonder at Phoenix Theater sold out!

Wonder was conceived/directed/choreographed by Bruce Bierman, and created with Stagebridge Viewpoints/Composition Class by sharing stories of family and loved ones who have gone through some kind of memory loss. Bruce is an art prodigy who doesn't have to wait until he's past 60 to quit his day job and practice Art!

Engagement in health and well-being

Tiffany L. Chan, OD, presented Vision Care for Older Adults as part of Healthy Vision Month. She discussed the most common eye conditions that lead to vision loss (age-related macular degeneration, glaucoma, cataracts, diabetic retinopathy) and low vision rehabilitation (magnifiers, orientation and mobility, home modification, etc.).

Gerontologist Hope Levy of American Bone Health (ABH) presented Freedom from Fractures in conjunction with Osteoporosis Awareness Month. Some highlights of her talk:

· Osteoporosis only accounts for about 50% of overall risk for fractures

· Rapid bone loss occurs in women at menopause and in men at about age 70

· Warning signs of osteoporosis are loss of height and a fracture

· About 1 in 2 women, and up to 1 in 4 men, age 50+ will break a bone due to osteoporosis

· ABH Fracture Risk Calculator https://americanbonehealth.org/calculator/ estimates 10-year risk of breaking a bone, based on personal factors (age, gender, BMI, race), lifestyle factors (smoking tobacco, drinking excess alcohol), medications taken (prednisone or steroid pills, high doses of thyroid medicine), medical conditions (rheumatoid arthritis, diabetes, cancer, serious hormone deficiencies, organ transplant, longstanding malnutrition/malabsorption, chronic liver disease) and fracture history.

· Fracture risk can be reduced by osteoporosis medicine (if high risk), sufficient nutrients (calcium, vitamin D, protein), movement (weight-bearing, muscle-strengthening), and fall-proof home.

Lizette Martinez and Maria Guillen of Community Living Campaign presented The Informed Patient: Your Rights during a Hospital Stay. Some highlights:

· hospital patient rights

· tips for more effective doctor visits

· hospital inpatient/outpatient admission status for Medicare coverage

· proactive patient checklist

· challenging hospital discharge decisions

Engagement in social services

Woo-hoo! This month’s 31^st annual Meals on Wheels San Francisco (MOWSF) Star Chefs and Vintners Gala raised a record $3.3 million to support home-delivered meals and social work services to homebound older adults! In addition, MOWSF has raised more than $19 million on a $35 million capital campaign to build a new kitchen to serve the growing population of older adults who wish to age in place. In the past year, MOWSF delivered almost 2 million meals to more than 3,600 seniors. With almost 75% of MOWSF clients living below the Federal Poverty Line, MOWSF provides a crucial safety net.

Robin, Lara and Regina of MOWSF Social Work Department connected with Patrick Arbore, founder of Friendship Line at its 45^th Anniversary Celebration at Institute on Aging. Today the Friendship Line is the only 24-hour, toll-free, accredited crisis intervention telephone line (1-800-971-0016) for older adults and adults with disabilities. Friendship Line volunteers make and receive an average of 12,000 calls every month.

Engagement in advocacy works!

Residents from Rhoda Goldman Plaza saw resolution to pedestrian safety concerns raised last December during a walk audit with Walk SF and SF Municipal Transportation Agency (MTA) over uneven sidewalk and not having enough time to cross the streets outside their senior living community. This month, the uneven sidewalk was patched up with asphalt (photo above) and SF MTA pledged to retime traffic signals allowing an additional one second per feet to cross streets.

Monday, April 30, 2018

Reimagine End of Life

Reimagine End of Life (EOL) https://www.letsreimagine.org/ was a weeklong event that “envisions a world in which we are all able to reflect on why we’re here, prepare for a time when we won’t be, and live fully right up until the end.”

Conference founder Brad Wolfe said inspiration to create Reimagine event came from his grandparents’ experience of surviving Auschwitz: “What is so precious about life that, in the face of death, we are inspired to fight for more time?” Partnering with the San Francisco Palliative Care Workgroup, Reimagine offered 150 events that looked at EOL from perspectives of healthcare + social services, arts + entertainment, design + innovation, culture + spirituality.

Psychedelics and Death: New Science, New Understandings was a conversation between Temple Emanu-El Rabbi Sydney Mintz (who said Judaism does death well) and Richard Miller, PhD, clinical psychologist and author of Psychedelic Medicine: The Healing Powers of LSD, MDMA, Psilocybin, and Ayahuasca (2017). Richard said psychedelics help at EOL to remove cultural fear from death experience; he talked about LSD opening the mind to realization that the world is one breathing organism, all beings are connected, death is sleep without dreaming; his tombstone would state date of birth to blank date of death because “who’s to say”?

End of Life Project: A Theatrical Exploration of Death, Dying and Suffering was sold-out at Castro Theatre, filled to over 900 people.

Dramatic readings of scenes from Sophocles’ Philoctetes and The Women of Trachis by David Strathairn, Frances McDormand and Marjolaine Goldsmith. In both plays, there was a lot of screaming at the audience by actors portraying patients suffering in pain.

Community Conversation moderated by Bryan Doerries, founder of Theater of War, and featured panelists Eric Poche (Zen Hospice Project), Anne Germanacos (writer and “amateur student of death”), Steve Weitz (JFCS Palliative Care volunteer) and Bonnie Lasky (caregiver for her dying husband). What kind of EOL experience do we want?

One audience member talked about a dying loved one “covered up with meds” such that the person was no longer there, not awake when death happened. Is it worse to hear dying people scream in pain or be complicit to silence when dying people can no longer express themselves?

At the end of each Reimagine event, participants received a box of cards inviting us to:

1. Remember: (fill-in-name) who inspires me to (fill-in-blank). Included were cards with photos of public figures and their quotes: “Try to be a rainbow in someone’s cloud” by Maya Angelou (writer and first African-American female cable car conductor), “You gotta give room for people to experiment” by Mayor Ed Lee (who was also an organ donor), and “You need music, I don’t know why” by Jerry Garcia (Grateful Dead guitarist).

2. Prepare: (fill-in-name) is a person I can imagine talking to about helping me carry out my end of life wishes. Speak up about the things that are important to you (advance health care directive), help family and friends be your advocate (durable medical power of attorney), and for what you want to leave behind (will, after gifting).

3. Wonder: (fill-in-blank) when I think about end of life. Questions to ponder: where would you have your last meal? What would it be? Where do you want your remains to go after you die? If you could leave one piece of advice for the next generation, what would it be? What would you do differently if you knew that this was your last day? Year? Who would you spend time with? What would be important to say? Do you think life would be better if we could live forever?

At Yom HaShoah (Holocaust Remembrance Day on April 11) event, Gloria Hollander Lyon spoke about surviving seven concentration camps during the Holocaust and engaging in Tikkun Olam (repairing or healing the world) by bearing witness and speaking out against prejudice, discrimination and threats to civil liberties. Six candles (representing 6 million Jews killed) were lit by Holocaust survivors, followed by music (“Eli Eli” sung by Jan Peerce and “Avinu Malkeinu” sung by Barbra Streisand) before a screening of Gloria’s documentary, “When I Was 14: A Survivor Remembers." For the past 40 years, Gloria has dedicated herself to teaching the lessons of the Holocaust and published her memoir, Mommy, What’s That Number on Your Arm? A-6374. (I attended Gloria’s book release reception nearly 18 months ago, and now it was a privilege to work with her in organizing this moving remembrance program.)

At JCCSF’s 12^th Annual JCCSF Art of Aging Gracefully Resource Fair, Donald Abrams, MD, integrative oncologist at UCSF repeated Cannabis as Medicine presentation, including its use during end of life.

“Cannabis — also known as marijuana — increases the desire for food, makes foods smell better and taste richer, decreases pain and relaxes and elevates a person’s mood. Subsequent studies have confirmed these effects, in addition to cannabis’ effectiveness in reducing nausea and vomiting.

Patients at the end of their lives can have problems with appetite, nausea, pain, anxiety and sadness…

I see cannabis as an extraordinarily safe drug to be given if needed at the end of life.” –John Morley, MD, “Senior Focus: Should marijuana be legalized for end of life care?” St. Louis Post-Dispatch (Oct. 10, 2013)

In her new book, Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer (2018), 76-year-old Barbara Ehrenreich (a cancer survivor) writes that she’s given up on preventative care after realizing that she’s “old enough to die” (sounding almost like Ezekiel Emanuel’s “Why I Hope to Die at 75,” article published in The Atlantic almost four years ago):

“Once I realized I was old enough to die, I decided that I was also old enough not to incur any more suffering, annoyance, or boredom in the pursuit of a longer life. I eat well, meaning I choose foods that taste good and that will stave off hunger for as long as possible, like protein, fiber, and fats. I exercise—not because it will make me live longer but because it feels good when I do. As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me. Ideally, the determination of when one is old enough to die should be a personal decision, based on a judgment of the likely benefits, if any, of medical care and—just as important at a certain age—how we choose to spend the time that remains to us.”—Barbara Ehrenreich, “Why I’m Giving Up on Preventative Care: How Contemporary American Medicine is Testing Us to Death,” Literary Hub (April 9, 2018)

A recent Stanford University study, published in the Journal of Palliative Medicine, suggests an EOL approach to facilitate better “preference-sensitive” care and informed decision-making is for patients to share their bucket lists with physicians who can discuss the impact (if any) of their medical treatments on their life goals. Researchers hope their findings will promote more intimate discussions that focus on what patients want to make the most out of life, rather than over-reliance on advance directives that focus on death (though patients should still complete/update their advance directives). According to VJ Periyakoil, study author and director at Stanford Palliative Care Education and Training Program, regret is the most common emotion seen in patients when they are dying. She also noted that participants who said religion/spirituality was important were the most likely to have a bucket list, which suggests that faith allows “the ability to imagine something is a proxy for a level of hope even in the face of little evidence.”

Money magazine reported, “A Growing Cult of Millennials Is Obsessed With Early Retirement. This 72-Year-Old is Their Unlikely Inspiration” (April 17, 2018), referring to Vicki Robin, co-author of Your Money, or Your Life (YMoYL). (When I read YMoYL originally published in 1992, it inspired me to maintain my simplified lifestyle and reject consumerism because money=life energy; YMoYL has been revised to emphasize financial interdependence, such as a community building to share resources and support.) Apparently, millennials are focused on “Financial Independence, Retire Early (FIRE) with more emphasis on the goal of FI than what to do for the rest of their retirement lives before they die?! When older adults retire at age 70, the “biggest challenge is to make your life as meaningful as it was when you were working,” according to Dr. David B. Reuben, Chief of Geriatrics Medicine at UCLA. Towards the end of life, we may think even more about making a contribution to society based on Erik Erikson's theory.