Time in a bottle

When flying from San Francisco to Honolulu, sit on right side of plane for this aerial view passing Diamond Head.  Flygskam! Couldn’t I have set sail on a solar yacht instead, like Greta Thunberg and her father?  This month, 50-year-old Spanish endurance athlete Antonio de la Rosa paddled 2,900 miles from San Francisco to Honolulu.  His self-described journey of “absolute loneliness and self-sufficiency” to raise awareness about protecting the ocean from man-made pollution took over 76 days.

    

In contrast, I didn’t even last 76 days rowing for my college crew team, so I took a full passenger flight for 5 hours, contributing about .59 metric tons of carbon dioxide.  Climate change is real as much of Hawaii (sparing Honolulu) was declared a disaster (eligible for federal funding) after Category 5 Hurricane Lane last year.

This time-consciousness relating to travel reminded me of two favorite songs from the 1970s about time, coincidentally by singers who died in transportation crashes:

“If I could save time in a bottle
The first thing that I'd like to do
Is to save every day till eternity passes away
Just to spend them with you…
But there never seems to be enough time
To do the things you want to do, once you find them”

--Time in a Bottle (1973) by Jim Croce (died in 1973 airplane crash)

Cat’s in the Cradle (1974) sung by Harry Chapin (died in 1981 car crash) and written by his wife Sandy from the point of view of a busy father—when son asks to play, father brushes him off, time passes; father and son grow older, now father asks son to spend time with him; by now, grown-up son very busy so brushes off father who sings wistfully:

“I've long since retired, my son's moved away

I called him up just the other day

I said, "I'd like to see you if you don't mind"

He said, "I'd love to, Dad, if I can find the time

You see my new job's a hassle and the kid's got the flu

But it's sure nice talking to you, Dad

It's been sure nice talking to you"

And as I hung up the phone it occurred to me

He'd grown up just like me

My boy was just like me”

             

Once I landed in Honolulu, I lowered my carbon footprint by taking TheBus, carpooling and walking.  But mostly I was a homebody because I am more conscious of time ticking away…

Growing up in a free-range household, we were not homebodies but often out and about.  Both parents were busy working, my siblings and I (under influence of Tiger Mum) were busy in school and extra-curricular activities (including child labor in family business, fired/rehired many times!), and my grandparents (with dementia) enjoyed wandering.  With my grandparents dead and one storefront business sold, my parents have relatively more “free” time (though still managing other family business) so I make time to be with them during my wikiwiki visits.

Slow healing

While listening to slack key guitarist Makana’s “Deep in an Ancient Hawaiian Forest” (from The Descendants film soundtrack), I looked at forest bathing materials – struck by sign stating “Neuroscience shows that 50-year-olds can have the brains of 25-year-olds if they sit quietly and do nothing for 15 minutes a day.”  Yikes, better avoid that because I don’t want to revert to immature 25-year-old brain! (Researchers have found that short-term memory peaks at age 25, emotional intelligence in our late 40s, and crystallized intelligence in the late 60s or early 70s.)  

Uloha hosted “Under the Banyan Tree” talk on Forest Bathing Hawaii by Phyllis Look, Hawaii’s first and only forest therapy guide (trained in Costa Rica) certified by Association of Nature & Forest Therapy (ANFT).  Her role as guide is to open door by awakening senses for groups to connect to the forest = therapist.  Her point is to slow down.  She presented a power point presentation using anatomy of a tree to explain forest bathing:

·       Roots in Japanese tradition of shinrin-yoku (“forest bathing”), term coined in 1982 by Japan’s Forestry Minister to encourage its mostly urban population susceptible to karoshi (“death by overwork” legacy of competition and economic dominance from post-World War II reconstruction) to de-stress in nature while taking advantage of forests that make up nearly 70% of Japan, in a public health promotion program 

·       Trunk in science with 30 years of evidence-based research showing forest bathing therapy results in physiological (lower cortisol levels, higher natural killer activity, cardiovascular and immune health) and psychological (improved well-being and social harmony) health benefits from breathing phytoncides (wood essential oils) 

·       Crown relationship of reciprocity, so nature connection and culture repair arise together, like caring between Kalo (taro) as the older brother to kanaka (Hawaiians).

Phyllis wrote Chinese pictographs for tree + human = rest.  After working in SF Bay Area theater scene, she returned to Hawaii 20 years ago for “family reasons” and now enjoys an encore career that takes her outdoors as forest therapy guide. 

Phyllis offered us mamaki (Hawaiian nettle) herbal tea, invited us to join her 3-hour, 1-mile forest bathing walk through University of Hawaii at Manoa’s Lyon Arboretum.  Her forest therapy was featured in August/September 2019 issue of Hana Hou, in-flight magazine of Hawaiian Airlines.  She offered me kama’aina (Hawaii resident) discount for forest walk.

Instead, I spent slow time with my parents, including being present for house call visit by Jessica Ackerman, NP with Queen’s Medical Center (QMC) Geriatrics, who spent a whole hour with us! Pop is patient, Mum is primary caregiver, and I am pro bono gerontologist freely offering my assessments 😊.  My parents say different QMC geriatric specialists visit quarterly, but consistently good! Plus, they know to call me (“daughter in California”) if follow-up needed. So grateful for their thoughtful, unrushed care provided to Pop, who had been immobilized due to pain after falling twice in monster home.  With one-time epidural shot for pain, ongoing physical therapy to regain strength, and deprescribing meds, Pop has gotten much better! We are so relieved because he had polio in his youth, and worried he might have post-polio syndrome (experienced by some of my clients).  Now Mum wants her own geriatrician, as her internist as primary care physician gives her only 15 minutes.

Quick building a village

At Ala Moana Hotel, enjoyed breakfast at 15^th Annual Hawaii Floodplain Management Conference hosted by Hawaii State Department of Land and Natural Resources. 

With limited time, I only showed up for Hawaii Homeless Initiative presentation, which fit conference theme Ho’o Laulima (“Many Hands Working Together”)—as well as my return to community work with older adults who are homeless or at-risk of losing their housing.  Hawaii State Homelessness Coordinator Scott Morishige, MSW, described how government and private sector worked together to quickly build Kahauiki Village, which provides long-term, affordable rental housing ($725 for 1 bedroom, $900 for 2 bedroom) for homeless families with children (no mention about kupuna).  The Village’s plantation-style community was brainchild of local businessman Duane Kurisu, who had organized fundraising for survivors of 2011 earthquake and tsunami in Japan; this “Aloha for Japan” returned to Hawaii in the form of pre-manufactured units, previously used to house them.

Government’s contribution came in the form of State land transferred to the City via executive order and leased to Duane’s aio Foundation for 10-year term at $1 per year, and Governor’s emergency homeless proclamation (Hawaii has highest per capita rate of homelessness) to suspend regulations facilitating quickly build of infrastructure (utilities, sewer, electricity, water).

  

Relatively isolated with water on 3 sides and highway, near industrial Sand Island Access Road, this almost self-sufficient Village (on-site preschool, daycare, laundry, and market) apparently did not have to contend with protesting NIMBY neighbors. Scott emphasized that Village tenants are screened and selected by Institute of Human Services (social services agency) – targeting people who are “clean, no substance use, motivated to get out of homelessness” and able to take advantage of nearby employment opportunities like laundry business operated by Hawaii’s former First Lady.  Replication of plantation village for modern-day laundry service workers…no wonder kupuna excluded?! 

Project Manager Lance Takehara presented Case Study: Kahauiki Village, which was built up on a floodplain, avoiding low-lying areas.  Transplanting modular units involved adjustments like short doorway and installing whole fans.  Project began in Fall 2015, and tenancy began in 2018.

Hope there's a good evacuation plan in event of flooding disaster!

This quick build project reminded me of The Union’s 5-storey, 110-unit apartment development in West Oakland, after 10 days fitting together pre-assembled modular units for relatively affordable housing (but not designed for homeless families and their plantation labor). 

History

Hawaiian history has been about its many struggles over land use, and tourism/military/commercial development usually won over affordable housing and traditional uses like agriculture, threatening Hawaii’s food sovereignty.  While riding The Bus, bittersweet to see this patch of watercress farm (since 1928) near Pearlridge Mall and along Kam Highway with passing vehicles spewing exhaust pollution.  Also viewed nearby construction of Honolulu (snail) Rail Transit, very slow work in progress.  

At Honolulu Design Center, attended screening of Reel Wahine of Hawaii, an intergenerational project of young graduates of Hawaii Women in Filmmaking (Executive Director Vera Zambonelli, in photo above) making documentaries of veteran women filmmakers, including

·       Victoria Keith, schoolteacher-turned-filmmaker of Hawaiian culture documentaries focused on local land struggles, from the 1976-1997 

·       Heather Haunani Giugni, co-founded first woman-owned video production company and filmmaker of stories about native Hawaiians 

·       Ciara Leina`ala Lacy, “directher” of Out of State (2018) documentary about the rehabilitative role of cultural practices among Native Hawaiians in Arizona prison 

·       Anne Misawa, director of State of Aloha (2009) documentary about Hawaii's history, motivating paths toward statehood and its legacy 

McCully-Moiliili Library commemorated its 50^th anniversary with a screening of Under the Blood Red Sun and talk with 75-year-old Graham Salisbury, haole author of 1994 novel that inspired film, and Tim Savage, director of 2014 film.  The novel focused on racial tensions following the 1941 Japanese attack on Pearl Harbor, as seen through the eyes of a Japanese boy living on Oahu with his immigrant grandfather and parents; the film was local production with mostly local cast.  Graham is a descendant of Thurston Twigg-Smith, Honolulu Advertiser publisher who wrote Hawaiian Sovereignty: Do The Facts Matter? (1998) and Lorrin A. Thurston, leader of Annexation Club instrumental in overthrow of Hawaiian Kingdom that replaced Queen Liliuokalani with Republic of Hawaii. (Pictured above is librarian in long-sleeved turtleneck, appropriate given air-conditioning blasting inside library, while it was sweltering hot outside, typical summer weather in Honolulu.)

Admission or Statehood Day is a holiday (3^rd Friday in August) in Hawaii that is not celebrated with fanfare.  Hawaii State Library hosted The Promise of Statehood: Looking Back, Moving Forward, with exhibit commemorating the 60^th anniversary of Hawaii’s statehood and a “Try Think” community discussion on “What do we dream for the future generation of Hawaii” with panelists: Anne Misawa (one of Reel Wahine of Hawaii); John Rosa, UH History Professor; John Waihee, former Hawaii governor and leader in 1978 Constitution Convention and formation of Office of Hawaiian Affairs; and Dean Itsuji Saranillio, author of Unsustainable Empire: Alternative Histories of Hawaii Statehood (2018) and critic of ongoing U.S. occupation (including Thirty Meter Telescope on Mauna Kea) and Asian settler colonialism in Hawaii. 

Waihee, age 13 when Hawaii became a state (only kupuna on panel), said he viewed statehood as civil rights victory against racism during territorial era, and supported ability to elect its own Governor.  Native Hawaiian Waihee represented his self-interest as he was elected 4^th Governor of Hawaii (1986-1994) during a period marked by tourist industry boom and increased foreign investment, mostly from Japan. To this day, many Native Hawaiians (Kanaka Maoli), whose ancestors were dispossessed of their lands, regard Hawaii statehood as continuing illegal occupation and motivated by capitalist greed of haole and Asian settlers. 

Statehood enabled Hawaii residents to vote for current Governor David Ige, best known for his delay in communicating correction about false ballistic missile alert because he forgot password to his Twitter account! 

At Made in Hawaii Festival in Blaisdell Center, surprised to see stand-up comic Frank de Lima doing “sit-down” comedy until he explained he had hip replacement surgery.  Now age 70, he remains the one comedian who can do gentle ethnic humor due to his own inter-ethnic background, descended from indigenous (Hawaiian), colonial settlers (Irish, English, Spanish, Scottish), and plantation immigrants (Portuguese, Chinese). 

To folks outside Hawaii, ethnic humor might seem politically incorrect—and some are downright sarcastic and demeaning.  But Frank might be an exception and his impersonations—especially of his multi-ethnic neighbors—might suggest empathy, as he views his contribution to peace:

“Hawaii's ethnic humor developed in the plantation days when people had humility, which they needed because if they weren't humble, the pride everybody has could have turned into arrogance and hatred and violence. Instead it turned into humor. And there was a lesson that went out through the years. Most people can handle Hawaii's humor, not everybody. But during the plantation days, most people could find humor in the different ethnic behaviors, and that's why there was peace.”—Frank de Lima, Acid Logic 

Frank’s “sit-down” comedy extended beyond ethnic humor. To tune of Jackson 5’s Rockin’ Robin, Frank sang these clever lyrics:

“Donald Trump

I sit in the White House all day long

watching TV and getting the news all wrong

with the news reporters

I grab my phone and I tweet tweet tweet

Tweeting Donald, tweeting Donald”

Derek Kurisu (older brother of Duane who inspired Kahauiki Village) introduced Chef Sam Choy, who used to say “never trust a skinny cook.”  Surprised to see his weight loss, but trust that 76-year-old Sam still knows how to cook… he made Hawaiian Poi Beef Stew using local ingredients like breadfruit (ulu), Hilo sweet potato, poi.

“Aging in Place”

Back at Ala Moana Hotel, 13^th Annual Aging in Place event was a mix of workshops (few informative, mostly marketing) and providers exhibiting their products and services (lots of assisted living facilities, though they really should not count for “Aging in Place”).  Visited Kupuna Pono, program of non-profit The Mediation Center of the Pacific, designed to help “families talk and support their kupuna” including advance care directive family conferences.  It was formerly named Neighborhood Justice Center, where I did an undergraduate internship!

Eileen Phillips, RN, discussed Understanding Your Home Care Choices.  (Reassuring familiar face as I took her Fall Prevention class years ago!)  She didn’t talk about me and family members (unpaid caregivers), but how to choose among 150 home care agencies in Hawaii that charge at hourly rates starting at companion level of $24 (minimum 3 hours per day).  

Afterwards, I walked couple of blocks over for tour of The Plaza Assisted Living at Waikiki.  It had the vibe of a cruise ship, but windows did not open for access to nature like breeze from trade winds, air from outdoors—just stuck with air-conditioning indoors, 24/7 year-round—like TheBus, hospital, and other controlled environments; no balconies, though there was patio on 3^rd floor facing Kalakaua Avenue traffic. 

I don’t like how air-conditioning has taken over; rather welcome humidity which is like natural skin moisturizer. Very sad to see wooden jalousie windows closed shut in older buildings and window mounted air-conditioners blocking out access to fresh air and natural sunlight.

Though made in Hawaii, I never felt like I belonged – I used to say I felt like an outsider.  Now I think it’s more accurate to say I didn’t feel at home in Hawaii because its land and culture has been hijacked by U.S. military, tourism, horrendous traffic, and air-conditioning!

   

In politically correct SF, there’s often an acknowledgement of being on indigenous land; unless one is indigenous, everyone else is an outsider.

Wonder what “aging in place” means for Kanaka Maoli? Hawaiian nationalist Haunani-Kay Trask gave advice about going away for college, leaving Hawaii because it’s too small, to find your voice because one always has to be too careful about what to say/what not to say in Hawaii, like definitely “no make waves” though surrounded by water?! “Get out of the colony” or drown.  How does one feel at home without free expression?

The end

“You better know that in the end
It's better to say too much
Than to never to say what you need to say again…”

--John Mayer, “Say (What You Need to Say)” from The Bucket List (2007) 

Lori Protzman, RN, Advance Care Planning Coordinator at QMC, presented all-day Ain’t the Way to Die: Advance Care Planning Workshop.  She reminded us that 5% of patients “create” 50% of health care costs, including 1/3 during last month of life; nearly 20% of deaths occur in ICU or immediately after discharge (“treated to death”).  Objective: help patients and families “say what they need to say” and let them know they were heard. 

What’s a good death from perspectives of Family, Patient and Health Care. Goals of care: concentrate on improving quality of life; help live meaningfully in time you have; ensure you receive kind of treatment you want; comfort and dignity will be our top priority. 

Lori recommended watching film, The Farewell, based on Taiwanese director Lulu Wang’s own experience with her dying grandmother, and her family wanting to hide terminal diagnosis from her and planning fake wedding as excuse for family reunion. 

I like palli care doc + cartoonist Nathan Gray’s Dying Words Aren’t What I Imagined. 

Back in SF Bay Area

At this month’s SF Bay Area Network for End-of-Life Care meeting, Lonny Shavelson, MD, presented on Medical Aid in Dying: Ethically Challenging Cases (and a pharmacology update!).  Based in Berkeley, he is a former emergency room physician, author of A Chosen Death: The Dying Confront Assisted Suicide (1995), and founder of Bay Area End of Life Options for patients at the end of their lives who are considering various options, including medical aid-in-dying (MAID) under California’s End of Life Option Act (2016).  He said writing a lethal prescription for terminally ill patients is “last resort,” with purpose for “dignified death” (never use “death with dignity”) after considering hospice and palliative care options.  He also consults with physicians and plans train-the-trainer as he intends closing date for his practice.  Always at his patients’ bedside, he highlighted challenges:

·       Secobarbital (induces sleep into coma so brain stem no longer drives respiration) cost increased to $3,500, then “disappeared from market”; DDMP2 (valium + morphine suppress respiration for cardiac arrest) takes longer for effect.  Taking more than 4 hours to die after ingesting lethal meds is “problematic,” less than 2 hours possible after “playing with meds.”  Brain damage can result from incomplete AID.

·       30% of terminally ill patients eligible for MAID died during 15-day waiting period; most oncologists decline to participate, and refer to primary care physician, who has no training, so refer to hospice which provides consulting MD, but only attending MD can start 15-day waiting period.  In July 2019, Oregon amended its law to make it ok to administer drug during waiting period if death is imminent.

·       If terminally ill patient loses ability to swallow (oral self-ingest), self-administering meds or ingestion can take place using GI tract, feeding tube or rectal catheter, with patient pushing syringe.

Meeting Co-Chair Nate Hinerman introduced psychiatrist and bioethicist Stanley Terman, MD, PhD, of Caring Advocates.  Dr. Terman is proponent of VSED (Voluntarily Stopping Eating and Drinking) as alternative to MAID. 

Scribd hosted How to Live Life and Face Death with UCSF palliative care physician BJ Miller & Shoshana Berger, co-authors of A Beginner’s Guide to the End: Practical Advice for Living Life and Facing Death, discussing what really matters, how to prepare for the inevitability of death, and make the most of life before that time comes. 

Researchers are getting closer to developing a blood test that predicts when a person will die.  Last month, California Department of Health issued report finding that 88% of people who use California’s EOL Option are white. 

In Oakland, attended Racial Equity, Homelessness, and Homeless Systems of Care, hosted by Bay Area Regional Health Inequities Initiative (BARHII coalition of public health departments) and Homebase.  BARHII Executive Director Melissa Jones discussed roots of crises from structural racism: homelessness is result of failed housing policing and systems v. individual/behavioral issue for intervention.

According to Point-in-Time counts, SF Bay Area has the 3^rd largest population of people experiencing homelessness (28,200) in the U.S., behind NYC (76,500) and Los Angeles (55,200).  Bay Area also shelters a smaller proportion of its homeless (33%) than any metro area in U.S. besides Los Angeles (25%), making crisis highly visible. 

Bay Area’s homeless population is disproportionately comprised of single, male minorities age 25+.  Meeting focus on race so no breakdown for older adult age range provided.  African Americans, Native Americans and Latinx are overrepresented among homeless.  Bay Area Asians were reported to have 0.1x homeless rate relative to general population, so I asked whether this was due to Asians living in multi-generational households like 6 people crammed in single-room occupancy unit with bunk beds? Who knows?! Group activities involved using Government Alliance on Race & Equity toolkits. 

Lunch included soda + chips below “health happens here with prevention” poster!

At SF Village, Palo Alto University Professor Lisa Brown presented on Climate Change and Healthy Aging, discussing impacts of rising temperatures, flooding and changing wind patterns; how to stay safe and make a difference with Elders Climate Action and next month’s Global Climate Strike with 1000 Grandmothers.

Finally, another reminder about breathing from geropsychologist Janet Meiselman, PsyD, who presented talk on Brain Health, Mindfulness, Mood & Memory.  And remember what we learned from forest bathing presentation: “50-year-olds can have the brains of 25-year-olds if they sit quietly and do nothing for 15 minutes a day.”

Breathing

STRESS! (Positive) cures for modern anxiety from Andy Warhol (1928-1987) exhibit at SF Museum of Modern Art

As a paid participant in the UCSF Stress and Resilience study this month, I was assigned to Method of Breathing and Shower (MOBS) condition.  (Other conditions were exercise and meditation.)  This stress resilience method involved daily morning breathing and hot showers for 21 consecutive days.  I was fine with hot showers, but did not like breathing as instructed by a 15-minute audio recording of a monotonous male voice that made me want to return to sleep:

“Inhale, exhale, in, out, breathe light and slow, slow inhale, slow exhale, in, out, no need to inhale all the way or exhale all the way, breathe naturally, softly and relax.

Inhale, exhale, in and out, focus on the breath with your full attention, breathing through the nose for both the inhale and the exhale.

Inhale, exhale, focus just on this even guiding breath, listen to the sound of your breath, and make it peaceful, soft and relaxed as possible…"

Conscious breathing exercises had to be done in the morning to “make the habit regular,” and on an empty stomach...before breakfast, so stomach rumbling in hunger was distracting.

At Anza Branch Library, Dr. Yangdron Kalzang of Kunde Institute-Center for Tibetan Wellness and Healing presented talk on Tibetan Medicine: Self-Care, which has influences from India (Ayurvedic), China (5 Elements) and Persia.  Tibetan Medicine focuses on digestive fire (immune system and internal disorders) and emotional/mental health (stress).  She outlined 3 "poisons of emotion": desire/attachment, hatred/jealousy, and ignorance/delusion.

Dr. Kalzang explained symbolism in Tibetan flag colors (similar to Traditional Chinese Medicine’s Five Elements): blue=space, white=air, red=fire, green=water, and yellow=earth.  Youth is associated with earth and water.  At older age 55+, fire is diminished, air picks up, water is unstable so there is dryness; instead of drinking lots of water that can overwork kidneys, Dr. Kalzang recommended consuming 1 tablespoon of oil (ghee) to quench thirst. 

Dr. Kalzang reviewed Progression of Mental Imbalance in Tibetan Medicine:  imbalanced lifestyle+dietà stressà anxietyàpanic attackà depressionà maniaà madness/crazinessà bipolarà forgetfulness.  Signs and symptoms of stress:

·       Physical: restless limbs/body, feeling light/ungrounded, wanting to stretch, constant yawning, insomnia, shaking with hunger

·       Mental: feeling overwhelmed, agitated/anxious, difficulty focusing/concentrating, jumping/monkey mind, short-tempered, paranoid

For stress relief, Dr. Kalzang recommended take a break and breathe. She also demonstrated the art and craft of making sachets of freshly ground nutmeg and caraway seeds wrapped in muslin fabric and secured with string.  To focus on breath, inhale aroma of herbs.  Add warmed ghee to ground herbs to make poultice for application to acupressure points on body; this Hormey treatment helps relax mind and body, reduces physical and mental stress, boosts immune system, clears the mind and improves concentration.  These “external accessory therapies” are cost-effective, safe and without harmful side effects.

About 70% to 90% of adults age 65+ have been exposed to a potentially traumatic event in their lifetime.  Sometimes conducting life review with older adults brings up past trauma, so taking deep breaths can help bring us back to the present.  
Deep breathing’s role to keep us present was reinforced during SF Department of Public Health (DPH) training on Trauma Informed Systems (TIS) Initiative—Transforming Stress and Trauma: Fostering Wellness and Resilience.  Other take-aways:

·       “Connection is the healing balm of trauma.”

·       Shift perspective from “What is wrong with you?” to “What has happened to you?” to provide context, foster compassion, help us see strengths in face of adversity.

·       Chronic stress can trigger brain into survival mode, so emotion brain (limbic system) takes over thinking brain (prefrontal cortex); aggravating behavior is a “cause for a pause”: before react, pause & take a breath, ask “What has happened to you? What is happening here? What is the need behind this behavior? How can I respond to this need?”

·       Health disparities: what’s wrong? Race+Place=Health; what happened? Trauma (insidious, historical, institutional)àCommunity violence=Health

·       Context matters: oppression, racism, sexism, classism, xenophobia, inequity, homophobia

·       Understanding community level traumaàpromoting community resilience: opportunity (intergenerational poverty, divestmentàeconomic empowerment, quality education, restorative justice); people (fragmented social relationships, destructive social normsàrebuild relationships, strengthen healthy social norms); place (unsafe public spaces, deteriorated environments, unhealthy productsàsafer public places, invest in environments, available healthy products)

·       TIS principles in action: understand trauma & stress (find out ACE score and resiliency score https://acestoohigh.com/got-your-ace-score/); cultural humility & responsiveness (take implicit bias test https://implicit.harvard.edu/implicit/); safety (physical, social, emotional) & stability; compassion & dependability; collaboration & empowerment (foster voice & choice: Ask, Respond, Clarify, Confirm “Does this work for you?”); resilience & recovery (practice gratitude)

·       Relationships are central to healing: healthy relationships involve attunement (being sensitive, responsive, in harmony with feelings & needs of ourselves & others)

·       Relationship building tool—Connect, then Re-Direct PEARLS: Partnership (“Let’s work together”), Empathy (“That sounds frustrating”), Apology (“I’m sorry that happened”), Respect (“You have gone through a lot”), Legitimation (“It makes sense that you feel this way”), Support (“Let’s see what we can do”)

Half-day TIS was followed up with 2-day SF DPH Trauma Initiative Search Inside Yourself Leadership Institute (SIYLI), based on Search Inside Yourself: The Unexpected Path to Achieving Success, Happiness (and World Peace)(2012) by Chade-Meng Tan, retired Google engineer and Jolly Good Fellow.  Last summer, corporate mindfulness merchant Meng stepped down as chair of SIYLI over "inappropriate behavior."

I pondered: What does it mean to achieve success in Public Health? Is there more to life than happiness? Why did training video clips (and most of book) show only male talking heads reflecting tech bro culture?  What happened to “context matters,” inclusion and diversity? This exclusion of female voices (lack of cognitive diversity) is troubling; last month, National Institutes of Health Director Francis S. Collins finally acknowledged that “it is time to end the tradition in science of all-male speaking panels” so he will no longer accept invitations on such “manels.” 

SIYLI micro-practices, appropriated from Buddhism, focused on more breathing for mindfulness-based emotional intelligence:

·       Mindfulness: listening (with attentiveness, kindness, and curiosity); 3 breaths (1^st attention to breathing, 2^nd relax body, 3^rd ask “What’s important right now?”); focused attention; minute to arrive (start meeting with 1 minute of silence to help everyone be fully present); open awareness; noting (when you feel stuck: notice it, name it, let it be, and just breathe)

·       Self-awareness: body scan; head, body, heart check-in with 3 breaths (1^st breath scan head=thoughts, 2^nd scan body=emotions + sensations, 3^rd scan heart=values/intentions); journaling; mindful eating

·       Self-management: SNBRR (Stop, Breathe, Notice, Reflect, Respond—when triggered); mindful conversation (listen, repeat back to check understanding with speaker); self-compassion; acceptance (take breaths in & out, “Breathing in, I do my best; breathing out, I let go of the rest”—when distressed)

·       Motivation & resilience: values & envisioning journaling; hands on chair (let feeling of chair fabric be “mental cue to remember your intention for how you show up”); resilience (breathe in & out with feelings and recognize them as temporary to create mental space for “wise response & growth”)

·       Empathy & compassion: "just like me" & offering kindness (bring to mind people you know & work with, consider your common humanity, wish them well); shift to connection (take 3 breaths to build connection with others in the moment—1^st breath to settle the mind, 2^nd breath to see similarity, 3^rd breath to offer kindness); walking meditation (savor process of walking, attention to sensations including transfer of weight from one foot to next and feet on ground); empathetic listening (to feelings and words)

·       Leadership: difficult conversations preparation by thinking through 3 levels (content, feelings, identity) from each person’s point of view; impact is not intention (when you notice feeling irritated/frustrated with someone, consider 3 levels that may be driving other person’s behavior); compassion practice (when encountering someone in distress, pause & reflect on situation, attention to what they are experiencing, invite positive wishes for them); ask “what would be of service?” (get to core of what’s important)

Our self-motivation comes from flow channel (diagram pictured above) which occurs when challenge matches your skill level, similar to person-environment fit.  Meng covered this “art of self-motivation” in his book’s chapter 6 on “Making Profits,” citing male TED Talk authorities like tech bro Tony Hsieh (author of Delivering Happiness: A Path to Profits, Passion, and Purpose), Daniel Goleman (Emotional Intelligence), Mihaly Csikszentmihalyi (Flow: The Psychology of Optimal Experience), and Daniel Pink (Drive: The Surprising Truth About What Motivates Us). Later in this chapter's envisioning practice section, Meng mentioned a few female authorities, like his friend Roz Savage (first woman to complete Atlantic Rowing Race solo, so motivated after writing her obituary reflecting on the life she aspired to live that she gave up her “old life” to pursue her dream of rowing across oceans) and Barbara Fittipaldi (CEO of Center for New Futures); more breathing in resilience section citing Matthieu Ricard (co-author with Goleman of Happiness: A Guide to Developing Life’s Most Important Skill); and then discussing optimism, Meng cited positive psychologists Martin Seligman (Learned Optimism: How to Change Your Mind and Your Life) and Barbara Fredrickson (Positivity: Top-notch Research Reveals the 3 to 1 Ratio That Will Change Your Life).  

SIYLI training cost $1,250 but I attended through SF DPH at no cost, other than 2 days of my time and skepticism.  Much of this mindfulness material (minus videos of male talking heads) is covered in Stanford Chronic Disease Self-Management Program (which I delivered as workshop facilitator while employed at On Lok, and supplemented self-efficacy approach with linkages to community resources to address social determinants of health in supporting participants' weekly behavioral action plans).

Jenée Johnson, SF DPH Program Innovation Leader for Mindfulness, Trauma and Racial Equity (would be helpful to add Gender Equity), invited SIYLI graduates to Mindfulness Meet-Up so we could continue “integrating self-awareness, self-management, empathy, resilience and compassion into our lives and work.” Mindful magazine staff showed up to take photos to accompany upcoming article about DPH’s mindfulness efforts.

Ron Purser, SFSU Professor of Management, described his participation in SIYLI:

“The workshop was an amalgam of childish icebreakers, turn-to-your partner exercises, three-minute breathing meditations, and a hodgepodge of superficial materials on emotional intelligence as a pathway to career success, along with the usual neurobabble that meditation changes your brain…

What’s happening with corporate mindfulness is a complete denigration of critical thinking into the causes of stress, which are all privatized into the individual. There is also an implicit denigration of collective action and building solidarity. This trope is so common—“Change always starts from within. We first have to change ourselves, take self-responsibility, do self-care.”… The fact that these corporate initiatives are also [do it yourself] undercuts social change. It’s sending individuals a message that they are the problem, they need to be calm, and they need to regulate.

We’re always in a mode of trying to remake ourselves, refashion ourselves. We’re entrepreneurs of the self. Just look at the boom in meditation and mindfulness apps. The products are being hawked. Everything is about mustering our internal resources in an enterprise culture where subjectivity is monetized as mental capital and we’re human capital.

But we don’t look at how external resources in the social and political environment are really what helps us become more resilient. Do we have sick days at work? Do we have money in a savings account? Do we have neighbors who can help us out? Do we have health care? All of these things are much more conducive to building resilience than these gadgets and techniques being marketed...
Mindfulness is a very unregulated industry…where anyone can hang out a shingle... 
It seems innocuous. What’s wrong with a three-minute breathing exercise? What’s wrong with that, you know? Well, nothing particularly. But can we aim a little bit higher?”—Ron Purser, author of McMindfulness: How Mindfulness Became the New Capitalist Spirituality, interviewed by Zachary Siegel, “Why Corporations Want You to Shut Up and Meditate,” The Nation (July 25, 2019) 

Could deep breathing fresh air have the same effect of relaxing people who use smoking/vaping (breathing carcinogens) as a form of stress relief? Last month, headed over to Oakland Museum to attend Alameda County Behavioral Health’s Tobacco Conference, Vaping Nicotine: How Safe is it for Our Communities? where I was greeted by these posters showing smoking prevalence among vulnerable populations (chronically homeless, incarcerated, HIV infected, low-income, mentally ill/SUD) and behavioral health/psychiatric co-morbidities (OUD, schizophrenia, bipolar, alcohol use, SUD, anxiety).  Centers for Disease Control and Prevention recommended that mental health facilities go smoke-free and stop providing cigarettes to patients as an incentive/reward. 

No data based on age, but vaping among older adults as a form of harm reduction to quit smoking seems to have gone mainstream since Paula Span wrote “Some Older Smokers Turn to Vaping. That May Not Be a Bad Idea” in The New York Times (December 8, 2017) and Jia Tolentino wrote “The Promise of Vaping and the Rise of Juul: Teens have taken a technology that was supposed to help grownups stop smoking and invented a new kind of bad habit, molded in their own image,” in The New Yorker (May 14, 2018). 

Gurinder Singh Wadhwa, DO, shared research showing that despite intentions for harm reduction, many smokers do not transition fully from smoking to vaping; instead, they become dual users increasing nicotine consumption.  People with behavioral health conditions consume 42% of all cigarettes, while research suggests quitting tobacco decreases depression and anxiety.  Further, integrating tobacco treatment into behavioral health treatment can help clients with tobacco addiction. 

Phil Gardiner, DrPH, Senior Program Officer at UC Tobacco Related Disease Research Program (TRDRP) and Co-Chair of African-American Tobacco Control Leadership Council (AATCLC), likened vaping as another addictive tobacco product to menthol cigarettes marketed to African-Americans over the past half-century.  Tobacco-related diseases are #1 cause of death in African-American community, killing over 45,000 a year. (See 15-minute documentary, “Black Lives/Black Lungs.”)  Yet, 90% of black organizations, including Congressional Black Caucus, accept tobacco money so they don’t speak against tobacco industry that is killing black lives.

After the power point presentations, we enjoyed working lunch over discussion circles: Stanford Tobacco Toolkit (targeting schoolkids); Power of Marketing (SF-based Juul has 76% of vaping market share, $1.6 million marketing budget targeting young users); Vaping Devices Deconstructed (1 Juul pod=20 cigarettes worth of nicotine!); Advocacy Work (community participation is driving force behind adoption of Tobacco Retail Licensing ordinances that prohibit sale of flavored tobacco, establish minimum price floors and package size requirements for tobacco products and limit tobacco retailers per capita); and Tobacco Dependence Treatment Providers and Resources (pictured above, Project Eden provides outpatient services to adults with substance use disorders, using harm reduction though term not used because funding based on abstinence model). 

SF passed an ordinance banning the sale and distribution of e-cigarettes, pending a Food and Drug Administration (FDA) review of their safety, including inhaling secondhand vapor, presumably to protect children.  Never mind FDA already requires health warning labels on all tobacco products,  SF did not go so far as to ban conventional cigarettes that kill more than 400,000 Americans each year.  Instead, Beverly Hills became first U.S. city to ban sale of tobacco products except cigars, effective 2021. 

Surviving

SF DPH’s Supporting Health by Empowering & Lifting Leaders (SHELL) hosted an interactive seminar, HIV Long-Term Survivors with Tez Anderson, founder of Let’s Kick ASS (AIDS Survivor Syndrome) and HIV Long-Term Survivors Awareness Day (June 5, when CDC reported first cases). Tez came out of the closet at age 17 (in 1977), diagnosed HIV+ in 1983, had “mid-life” crisis at 26 (in 1986) when he was told he had only two years to live, which made him think short-term so he had no plans for college or saving money.  He moved to SF Castro gay mecca, where death and the expectation of dying was prevalent.  He experienced anger, severe anxiety and depression; he sought help from therapists, but the ones he could afford did not know how to help because they were trainees and too young to understand.  After Highly Active Antiretroviral Therapy (HAART) was introduced in 1996, HIV was transformed from a death sentence to a chronic, but manageable condition. 

Today more than 60% of people living with HIV are age 50+, and these long-term HIV survivors face unique challenges entering old age: poverty, social isolation/withdrawal, survivor guilt (ASS v. PTSD), and harmful side effects from early medications (neuropathy, enteropathy, arthritis, diarrhea, etc. which impair mobility and engagement when they “need community more than ever”).  Now age 60 and married for 12 years, Tez views aging as inevitable and a privilege because people have value in experience, so he embraces wrinkles and graying hair.  He also discussed ageism, like not bothering to test old people for sexually transmitted diseases, and PrEP marketing to young. 

At SF Main Library, journalist Keli Dailey hosted Surviving San Francisco: The Free Advice Show with panelists: 

·       Karen (Central City SRO organizer): museum free days, free cycle, free films via SFPL’s Kanopy (video streaming)

·       Dro (stand-up comic): work in food industry for free meals

·       Peggy (social worker turned start-up tech activist): survived on social worker salary $30K-60K by living in rent control unit and being frugal

·       Mark (civic tech entrepreneur): find out Henry George’s 19^th century solution to income inequality by taking free walking tour with David Geisen 

SF Public Library system is the real deal for surviving SF for all ages, including its accessibility services.  For the past 10 years, SF Main Library's psychiatric social worker helps library patrons who are homeless connect to support services. Research also shows library visits are equivalent to getting a pay raise!  

During July 4^th weekend, joined American Independence was all about land: walking tour with David Giesen. Starting at the Hostel in Union Square and walking east to Chinatown and Financial District, David talked about various social movements: charity (Glide Church’s fight against poverty, more about changing individual v. transforming society), utopian communist (back-to-the land Diggers, Mormons, American Indian occupation of Alcatraz, Jim Jones and People’s Temple, Occupy), revolutionary socialist (Black Panthers, who lived in building across from 701 Sutter Street building for sale with vacant ground floor retail space for lease below Legal Assistance to the Elderly’s 2^nd floor offices, pictured above in right corner), and geonomic (Judaism, Henry George). 

Sun Yat-Sen (1866-1925; 12-foot statue in St. Mary’s Square, Chinatown), “Father of Modern China,” got inspiration for his Three Principles of the People (nationalism, democracy, and social welfare) for China while in SF in 1905.  After reading Progress and Poverty (1879) by American journalist Henry George (1839-1897), Sun adopted the Georgist idea of equalization of land ownership based on a single tax on land values to generate government revenue for social welfare needs like clothing, food, housing, and transportation.

As State Assemblyman, Willie L. Brown, Jr. twice introduced land value tax legislation but was defeated; instead, California voters passed Proposition 13, People’s Initiative to Limit Property Taxation, in 1978, partly motivated by the idea that older Californians should not be taxed out of their homes.  Yet, after walking through many vacant lots, empty storefronts, and streets with unhoused people in the City, Georgism is appealing to encourage productive land use v. land speculation.

Margot Kushel, MD, Director of UCSF Center for Vulnerable Populations and Benioff Homelessness & Housing Initiative, presented a standing room only Grand Rounds talk, Aging Among Homeless Populations: An Emerging Crisis, at UCSF Mission Bay.  She talked about homelessness in SF and California, then shared findings from HOPE HOME (Health Outcomes in Populations Experiencing Homelessness in Older Middle agE), an ongoing longitudinal cohort study examining homelessness in adults aged 50+ in Oakland.

·       Homeless population is aging: proportion of single homeless older adults age 50+ in SF has grown to 50%, from 11% in 1990 and 37% in 2003

·       Cohort born 1955-1965 have elevated risk of homelessness during their lifetime because they came of age during recession and not able to make-up lost income, Reagan made massive cuts in federal affordable housing that were never restored—California is 2^nd worst, with only 22 units of affordable and available for every 100 extremely low-income households; only 34% of low-income, at-risk elderly households receive Section 8 rental assistance

·       Racial justice issue: Blacks are less than 6% of SF population, yet have 3-4x risk of being homeless.  Housing is primary means of wealth, yet there is discrimination in home ownership (segregation, redlining, predatory lending) and rental market.

·       HOPE HOME study: 450 participants, 77% men, 80% African-American

·       Pathways into homelessness: 44% of homeless studied experienced their 1^st episode of homelessness after age 50—most married; many worked multiple, minimum wage, non-union, physically demanding jobs; 3 triggers—job loss & unable to compete with high school education, sick & unable to continue physically demanding job, death of spouse/parent. (Contrast early onset homeless: traumatic adverse child experiences, mental health/substance use started in teen years, prison, TBI, etc.)

·       Health status: “50 is the new 75” (premature aging, prevalence of geriatric syndromes); self-reported multiple chronic conditions (hypertension, arthritis, hepatitis, asthma); higher proportion with functional impairment (1/3 have executive function impairment that interferes with following sequential steps to secure housing), substance use problems common to numb fear (65% drug use-cocaine, cannabis, opioids; 26% alcohol use); mental health (over 1/3 depression, 1/3 PTSD, 18% psychiatric hospitalization); high rates of acute care utilization, high mortality rate & institutional care (nursing home stays); majority obtain housing within 18 months

·       Interventions/solutions: deeply affordable housing (expand & preserve, target those who make <30% AMI; follow legislative efforts at National Low Income Housing Coalition), eviction prevention (just cause in SF, Oakland, San Jose; AB 1482 proposes state-wide just cause laws with limits on large rental increases), legal assistance, emergency housing assistance, rapid re-housing, permanent supportive housing (Housing First model, need to adapt for needs of older adults to age in place); advocate “housing is the best medicine” (push back against individual narrative—know how to treat serious mental illness, real solutions point to affordable housing)! 

Dr. Kushel joins discussion with graduate student Andy Kim and UCSF Institute for Global Health Sciences (IGHS) Executive Director Jaime Sepulveda.  Dr. Kushel said homelessness is vastly undercounted due to surveys in English and federal definition of homelessness does not include Asians who might have 8 people crowded in SRO.

Community Living Campaign’s Outer Sunset Connector Margaret Graf organized this month’s Senior Power presentations at Taraval Police Station with speakers from SF DPH’s Community Health Equity & Promotion (CHEP) and Safe Streets for Seniors. 

For older adults age 60+ living in SF, Community and Home Injury Prevention Program (CHIPPS) provides free home safety assessments and minor home safety modifications (if income eligible) because “seniors are happier and healthier living at home.”  Yet, people at home can risk injury from falls, scalds (hot liquid), burns (dry heat) and fires; and seniors may recover more slowly, leading to loss of mobility and independence, hospitalization and risk of death.  Injuries at home are preventable if we prioritize safety:

·       Changes in behavior: see doctor (get balance check, review meds that may cause instability/dizziness); get vision and hearing check (wear glasses with correct prescription, wear hearing aid if needed); regular physical activity (tai chi helps balance); wear right shoes (non-slip sole, breathable material, high back, flat/low heel, wide-mouth, no laces, soft and padded; if diabetic, podiatrist can write prescription for shoes paid by Medicare); careful if smoke (well-ventilated area, large ashtrays for butts, never in bed or lying down on couch; better to quit with help from 1-800-NOBUTTS)

·       Climate change: in SF, “extreme heat” is above 85F, can lead to dehydration, heat exhaustion and heat stroke; and will worsen conditions like heart disease, diabetes and respiratory illnesses.  Some tips during extreme heat: call family/friend to check in; avoid being outdoors 10 am–4 pm; drink plenty of water; take cool showers/baths; avoid alcohol; eat small meals that are low in protein; wear loose, breathable fabrics.  To find a cool place, check SF72.org or call 311.

·       Changes in home environment: get free home safety assessment; good lighting, reduce clutter and trip hazards; CHIPPS can provide surge protectors (do not run electrical cords under carpets to avoid sparks), install carbon monoxide detectors, annually test smoke and CO2 detectors, etc.

DPH Planner Mimi Tan presented Safe Streets for Seniors as part of Vision Zero: Eliminating Traffic Deaths and Reducing Injuries, highlighting SF’s novel creation of Vision Zero High Injury Network combining mapped data from SF General Hospital and SF Police to identify 13% of streets where 75% of severe and fatal injuries occurred, to prioritize safety improvements.  Seniors account for half of pedestrian deaths, yet only 15% of the City’s population.  In 2018, SF saw 23 traffic-related deaths.  To date this year, SF has already seen 21 traffic-related deaths so advocates have called for City leaders to declare a state of emergency for traffic safety. 

SF Hazards & Climate Resilience (HCR): People with Disabilities + Older Adults was an opportunity to provide feedback on draft HCR Plan strategies for existing buildings, new development, public awareness, housing, utilities, waterfront, transportation, etc. and build community while enjoying 100% plant-based breakfast and lunch provided by Nourish Café!

Jim Buker, Project Manager from One SF Office of Resilience and Capital Planning,  led efforts in partnership with Department of Emergency Management, DPH, Department of the Environment, and SF Planning.  Raimi Associates staff facilitated small group discussions.  Many of us in attendance experienced 1989 Loma Prieta earthquake (30^th anniversary on October 17) and 2017 Labor Day heat wave.  FEMA requires 5-year update local hazards plan, and draft document expected in November 2019.  SF residents can take HCR Survey at https://www.surveymonkey.com/r/SFhazards-English

David Munoz Ventura, Senior Project Coordinator with the Seismic Safety Outreach Program (SSOP) (pictured above with his colleague Jia) presented Personal Preparedness: A Seismic-Safety Plan for Older & Disabled Adults at Institute on Aging. SSOP is a partnership between SF Department of Building Inspection and Community Youth Center (CYC).  (CYC Program Director Michael Wong was former Asian Community Preparedness Manager of the American Red Cross Bay Area Chapter, running its Youth for Chinese Elderly Program, which partnered bilingual youth volunteers with monolingual Chinese elderly in emergency and disaster preparedness; since 2015, Michael brought this intergenerational model to CYC.) 

All training participants received SSOP for Senior Preparedness booklet and Dynamo Radio Light.  David reminded us that we survive through social cohesion, our interdependence, so get connected: use digital networks to stay informed via SFDEM, SF72org, 511 and 311; WhatsApp messaging; sign-up to meet neighbors on Nextdoor; upload important documents in cloud or Google drive.  For people with disabilities who are not able to Drop, Cover and Hold On during earthquake, David modified instructions to protect head and neck with arms/pillows, and do not head for doorway (unless you’re in 19^th century adobe home). 

Brain Awareness (last month)

At JCCSF’s 3^rd Annual Brain Fitness Forum, comedic monolinguist Josh Kornbluth performed Josh’s Brain Improv describing his experience as an Atlantic Fellow at Global Brain Health Institute of UCSF Memory and Aging Center.  With his credentials as a graduate of Bronx High School of Science and theatrical performer, he set out to learn as much about brain science to educate audiences about brain disease research and to help remove the stigma relating to people with dementia and their caregivers.  Josh’s Citizen Brain series can be viewed on his youtube channel. 

Forum ended with a documentary screening of Too Soon to Forget: The Journey of Younger Onset Alzheimer’s Disease (YOAD).  Up to 5% of the more than 5 million Americans with Alzheimer's are living with YOAD (diagnosed before age 65), which can be diagnosed as young as age 30. Congress has introduced YOAD Parity Health Act of 2019 (H.R. 1903/S. 901), which would allow individuals living with YOAD to access programs under the Older Americans Act (OAA).  Former New York Times reporter Phil Gutis, diagnosed with YOAD at age 54, has been chronicling his journey online.

Elder Care Alliance, a non-profit senior living organization, hosted afternoon Celebration of Dementia-Inclusive Art & Community at SOMa Cultural Arts Center: a drop-in “open classroom” where participants, who received Dementia-Inclusive tote bags, were free to enjoy refreshments, make art, view posters, sit at tables to respond (drawing, collage, writing, etc.) to prompts from issue cards stamped “Dementia-Inclusive Communities Initiative” about creating an “age-friendly” environment: care, culture, physical space and built environment. 

      

Interactive Let’s Redefine Age … woops, hard to read small print! Cards read: What are things you fear when you think about getting older?  What are things you love about your own aging process? For collection of responses, visit #Elevate Aging. 

On Lok 30^th Street Senior Center, which is celebrating 40 years, hosted 4-part How You Age Matters series. Center Director Valorie Villela introduced UCSF geriatrician Louise Aronson, who presented Many Faces of Dementia.  For Dr. Aronson, dementia is personal as her late father had Alzheimer’s and her mother has mild cognitive impairment.  Her recommendations:

·       Keep healthy and active:  eat a healthy/Mediterranean diet; exercise regularly; keep your mind active (consider brain training); don’t smoke; keep your weight, blood pressure, and blood sugar under good control; maintain at least a few close, personal relationships

·       Some things to do that improve life and your future, whether or not your have dementia:  Get evaluated; think about what matters most to you; get a hearing aid if you need one; stay active and social; make or update your advance directive; start doing all the fun things you can afford.

·       Communicating with someone with dementia:  NEVER reason, shame, say “remember?” or “I told you” or “You can’t”, condescend, force, abandon; INSTEAD, distract, reassure, divert, reminisce, repeat, offer simple instructions, be kind, provide choices, demonstrate, try a different approach, encourage and support

Good Life before Good Death

“…there is more of a romance to death than to aging currently…a good death is good, but hopefully it's pretty short and quick, right? Whereas we're talking decades of life and one of the things I like to say is do I know enough palliative care to give you a good death? Yes, but more importantly, I know enough geriatrics to give you a good life.
…if you look at a lot of health systems or other places, you'll see, oh here's pediatrics, here's adults, here's death. Oh, what happened in between? Oh we became invisible, we don't matter. And that's why we need elderhood because there are three phases whenever you're talking about kids and adults or childhood and adulthood, you need to invoke the elders and elderhood as well.”—Louise Aronson, MD, geriatrician and author of Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life, as guest at Geripal (May 30, 2019) 

At Dr. Aronson’s presentation at City Lights bookstore, sat behind Paul Kleyman, editor of Generations Beat Online.  Dr. Aronson explained that she originally called her book, Oldhood, because she wanted to reclaim the word “old.”  However, after someone pointed out that title would be grammatically incorrect, she changed the title to Elderhood.  (This contrasts with old-naysayer geriatricians like Juergen Bludau’s Aging, But Never Old: The Realities, Myths & Misrepresentations of the Anti-Aging Movement (2010)  and Marc Agronin’s The End of Old Age: Living a Longer, More Purposeful Life (2018) which opens with an introduction called, “Old is the Problem and Aging is the Solution," and leave it to Big Pharma to embrace “Get Old.”) 

SF Main Librarian Janet Tom introduced Last Wishes: Start Conversation Now.  (Representing Library Services to an Aging Population, Janet presented The New Frontier: Hot Topics to Engage Older Populations based on her Death & Dying series at the American Library Association’s Annual Conference, in Washington, DC! To increase access, Janet also arranged to have several programs in her Death series recorded for posting at SFPL youtube channel, starting with What Happens to My Body When I Die).  

Nancy Belza (financial services sales executive) and Paul Puccinelli, LMFT of Dyalogues (for-profit co-founded by Dawn Gross, MD in palliative care,) began with a cards exercise that was eerily similar to Go Wish (non-profit) intended to reduce stress and stigma around end-of-life discussions, while practicing our listening, empathy and curiosity skills for stronger connections.  (Stanley Terman, a psychiatrist, created My Way for Natural Dying cards through his non-profit, Caring Advocates.) 

Nancy and Paul instructed us to organize cards based on relative importance, and then invite our partners into this “gift of conversation” using these prompts because curiosity leads to discovery: Tell me more, What does that look like, How could I support you, How would I know, and Help me understand.

Take-aways:

·       This is about NOW: don’t have to wait to have these conversations.

·       Don’t assume to know what others want, without first having a conversation.

·       More than one conversation: life is dynamic, what matters most to us changes over time.

·       Talking about what matters at end of life, with those who matter, can ensure that our vision is respected and honored.

Shoshana Ungerleider, MD, introduced Ungerleider Palliative Care Lecture, Advance Care Planning with a Dementia Diagnosis to Lessen Suffering.

Catherine A. Madison, MD Director at Ray Dolby Brain Health Center, introduced Advance Directive for Dementia, developed by Barak Gaster, primary care MD at University of Washington, and profiled in The New York Times article published last year.  Dementia Directive is recommended for all patients at age 65, when they become at risk for cognitive impairment that could lead to dementia.

·       Because tough conversations rarely go as planned, provide prompts (for example, use Go Wish cards developed by geriatrician Elizabeth Menkin, MD) and then focus on listening, reflecting, learning and working on a common objective.

·       Become comfortable with your talking points, focusing on goals, function and quality of life.

·       Be flexible: “You look uncertain about this…We don’t need to decide today—at this moment.  Let’s talk more at our next meeting.”

·       Try mindfulness:  Pay attention in a non-judgmental manner, on purpose, to what matters most and bringing your whole self to the experience.

Dr. Gaster singled out dementia from multiple health conditions for an advance health care directive due to its nature as a slowly progressive neurodegenerative disease that leaves people with a long-time frame of diminishing cognitive function and loss of ability to self-care; many Americans who value autonomy may view living with advanced dementia as an unacceptable loss of dignity.  In contrast, the standard advance directive focuses on rare conditions like persistent vegetative state, permanent coma, or imminently terminal condition that do not apply to dementia.

Steve Heilig, MPH, Director of Public Health and Education at San Francisco Medical Society, echoed Dr. Madison’s views.