My Mother's Hip: Lessons from the World of Eldercare
http://www.100md.com
《新英格兰医药杂志》
American medicine increasingly reflects the face of elder care. The proportion of the population over the age of 65 increased throughout the 20th century, and it will increase markedly over the next two decades. Geriatric patients are the largest group of health care consumers, and they use an ever increasing portion of the care provided in emergency rooms, operating rooms, intensive care units, and rehabilitation centers. My Mother's Hip, by Luisa Margolies, provides a description of elder care akin to Hans Christian Andersen's fairy tale "The Emperor's New Clothes," with great monetary expenditure doing little to cloak our patients' naked suffering.
Margolies is a medical anthropologist, and she applies the techniques of that discipline to an examination of the final months of her mother's life. The book consists of eight chapters, seven of which are followed by a "lesson." In the chapters, the author uses ethnographic methods to examine her mother's progress through the health care system after she has bilateral hip fractures. The lessons provide didactic information about the major events in the preceding chapters, covering topics such as hip fracture, delivery of care, and advanced directives. The lessons will be of greatest interest to lay readers and health care providers without specialized knowledge. The chapters, rather than the lessons, were the parts that I found most interesting.
Margolies's tale illustrates both the phenomenal success of medicine in the treatment of disease and its profound failure in the treatment of individual persons. Her mother's many medical problems — polymyositis, rheumatoid arthritis, osteoporosis, bilateral hip fractures, pulmonary fibrosis, and pneumonia — were treated with state-of-the-art medical care, resulting in immediate physical benefit. Yet Margolies views the medical system as having failed her mother. At first glance, one might attribute this belief to a daughter's grief over her mother's inevitable death. Or one might assume that the author is chronically dissatisfied, given her litany of complaints about multiple providers at multiple facilities. However, to make these assumptions would be to overlook the dilemma the author is trying to share with us — the extent to which patients, families, and the health care system are stressed, and the degree to which the system fails, under the weight of chronic disease that results from our very successes.
Rehabilitation and end-of-life care are at the crux of this dilemma. Both issues involve the interface of disease with the social and environmental contexts; one has the goal of optimizing functional outcomes and the other the goal of ensuring death with dignity. Rehabilitation arose from the need to treat traumatic injury; thus, standard rehabilitation methods poorly fit the progressive disability, from multiple causes, that is typical of advanced age. Palliative care is dependent on acceptance of the imminence of death and on cultural attitudes about death; thus, the hospice model poorly fits those for whom death is uncertain, who are having difficulty accepting death, or whose cultural attitudes are profoundly different from the norm. This book underscores the importance of the need for further research on topics such as the strain on caregivers, the functional trajectory of illness and recovery in elderly patients, and the interface of religion and disease.
Although Margolies raises important issues, I found her insight into the solutions somewhat limited. She has an idealistic view of the state of elder care before Medicare became available. Forty years ago, her mother would not have survived bilateral hip fractures to have the post-acute care that Margolies finds problematic. The sentiments she ascribes to people with physical disability are simplistic; for example, she states, "Nothing is more painful than the day the chronically ill person realizes he or she cannot manage alone." Factors such as culture and personal history influence the myriad ways in which people adapt to chronic illness. For example, help from others may not be viewed negatively if it assuages loneliness or reinforces important family ties. Margolies does not address the philosophical question of where the responsibility of medicine to relieve suffering ends and that of society and of the individual person begins. Nonetheless, this very readable book offers a unique view of the effect that illness has on the entire fabric of a patient's life. It will be of interest to both physicians and nonphysicians involved in elder care, as well as to the elders themselves.
Helen Hoenig, M.D.
Duke University Medical Center
Durham, NC 27705
helen.hoenig@med.va.gov
Margolies is a medical anthropologist, and she applies the techniques of that discipline to an examination of the final months of her mother's life. The book consists of eight chapters, seven of which are followed by a "lesson." In the chapters, the author uses ethnographic methods to examine her mother's progress through the health care system after she has bilateral hip fractures. The lessons provide didactic information about the major events in the preceding chapters, covering topics such as hip fracture, delivery of care, and advanced directives. The lessons will be of greatest interest to lay readers and health care providers without specialized knowledge. The chapters, rather than the lessons, were the parts that I found most interesting.
Margolies's tale illustrates both the phenomenal success of medicine in the treatment of disease and its profound failure in the treatment of individual persons. Her mother's many medical problems — polymyositis, rheumatoid arthritis, osteoporosis, bilateral hip fractures, pulmonary fibrosis, and pneumonia — were treated with state-of-the-art medical care, resulting in immediate physical benefit. Yet Margolies views the medical system as having failed her mother. At first glance, one might attribute this belief to a daughter's grief over her mother's inevitable death. Or one might assume that the author is chronically dissatisfied, given her litany of complaints about multiple providers at multiple facilities. However, to make these assumptions would be to overlook the dilemma the author is trying to share with us — the extent to which patients, families, and the health care system are stressed, and the degree to which the system fails, under the weight of chronic disease that results from our very successes.
Rehabilitation and end-of-life care are at the crux of this dilemma. Both issues involve the interface of disease with the social and environmental contexts; one has the goal of optimizing functional outcomes and the other the goal of ensuring death with dignity. Rehabilitation arose from the need to treat traumatic injury; thus, standard rehabilitation methods poorly fit the progressive disability, from multiple causes, that is typical of advanced age. Palliative care is dependent on acceptance of the imminence of death and on cultural attitudes about death; thus, the hospice model poorly fits those for whom death is uncertain, who are having difficulty accepting death, or whose cultural attitudes are profoundly different from the norm. This book underscores the importance of the need for further research on topics such as the strain on caregivers, the functional trajectory of illness and recovery in elderly patients, and the interface of religion and disease.
Although Margolies raises important issues, I found her insight into the solutions somewhat limited. She has an idealistic view of the state of elder care before Medicare became available. Forty years ago, her mother would not have survived bilateral hip fractures to have the post-acute care that Margolies finds problematic. The sentiments she ascribes to people with physical disability are simplistic; for example, she states, "Nothing is more painful than the day the chronically ill person realizes he or she cannot manage alone." Factors such as culture and personal history influence the myriad ways in which people adapt to chronic illness. For example, help from others may not be viewed negatively if it assuages loneliness or reinforces important family ties. Margolies does not address the philosophical question of where the responsibility of medicine to relieve suffering ends and that of society and of the individual person begins. Nonetheless, this very readable book offers a unique view of the effect that illness has on the entire fabric of a patient's life. It will be of interest to both physicians and nonphysicians involved in elder care, as well as to the elders themselves.
Helen Hoenig, M.D.
Duke University Medical Center
Durham, NC 27705
helen.hoenig@med.va.gov