Palliative care as a true art form

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How do you ease the pain from an ailment amidst lost words? How can you serve the afflicted when lines start to blur? When the foundation of communication begins to crumble, what will be the pillar health-care professionals can lean on to support patients afflicted with dementia during their final days?

The practice of medicine is both highly analytical and evidence based in nature. However, it is considered a “practice” because at the highest level, it resembles a musician navigating an instrument. It resembles art. Between lab values, imaging techniques and treatment options, the nuances for individualized patient care so often become threatened.

Dementia, a non-malignant terminal illness, involves the progressive cognitive and social decline in those afflicted. Though there is no cure, dementia is commonly met in the setting of end-of-life care. During this final stage of life, the importance of comfort via symptomatic management and communication usually is a priority in patient care. But what about the care of a patient suffering from dementia? While communication serves as the vehicle to deliver care at a high level, medical professionals are suddenly met with a roadblock. And there … behind the pieces of shattered communication and a dampened map of ethical guidelines, health-care providers are at a standstill.

It’s 4:37 a.m. You receive a text message from the overnight nurse at a care facility regarding a current seizure. After lorazepam is ordered and administered, Mr. H, a quick-witted 76-year-old, stabilizes. Phenobarbital 15mg SC qhs was also added to prevent future similar events. You exhale a sigh of relief.

Mr. H. has been admitted to the floor 36 hours earlier after having a seizure while playing poker with colleagues. Since he became your patient, he’s shared many stories from professional and family life with you, along with as many jokes as he could fit in between. However, over the course of the next seven days, Mr. H. would develop aspiration pneumonia, progressing to ventilator dependency and, ultimately, multi-organ failure with rapid cognitive decline.

What strategies and tools would you use to maximize the well-being of your patient during his decline? How would you bridge the gap of understanding between the patient’s family and health-care team to provide the standard of care that all patients are owed?

To give Mr. H. the type of care he would have wanted, upon his hospital admission, he should have been questioned about his understanding of illness along with the goals of care of the medical team. The patient should have been informed that it is imperative to adhere to the medical regimen implemented by his team along with the risks of not doing so. In the event disease-related complications arose, advanced directives should have been documented to avoid any unnecessary measures.

It is important to note, that with each change in status of the patient’s health status, the goal of treatment must be reassessed. The patient or surrogate decision-maker’s understanding of these goals is paramount in maintaining the patient’s autonomy. It is often said that effective communication is the bedrock of a healthy relationship. This is true regardless of type of relationship.

This is why I and Megan Vierhout wrote Integrated End of Life Care in Dementia: A Comprehensive Guide, a book targeted at providing a much-needed road map to navigate the many challenges involved in end-of-life care for individuals with dementia. Ultimately, our aim is to provide a compass for both health-care professionals and the families of those affected by the progressive effects of dementia. We provide practical advice on optimizing communication with individuals with dementia while taking their cognitive limitations, preferences and needs into account.

I invite you to explore the unpredictable terrain of end-of-life care for patients with dementia. Together, we can pave a smoother, sturdier path toward the practice of medicine as a true art form.

This article is republished from healthydebate under a Creative Commons license. Read the original article.

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  • Escape From The Clutches Of Shame

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    We’ve written before about managing various emotions, including “negative” ones. We put that in “scare quotes” because they also all have positive aspects, that are just generally overshadowed by the fact that the emotions themselves are not pleasant. But for example…

    We evolved our emotions, including the “negative” ones, for our own benefit as a species:

    • Stress keeps us safe by making sure we take important situations seriously
    • Anger keeps us safe by protecting us from threats
    • Disgust keeps us safe by helping us to avoid things that might cause disease
    • Anxiety keeps us safe by ensuring we don’t get complacent
    • Guilt keeps us safe by ensuring we can function as a community
    • Sadness keeps us safe by ensuring we value things that are important to us, and learn to become averse to losing them
    • …and so on

    You can read more about how to turn these off (or rather, at least pause them) when they’re misfiring and/or just plain not convenient, here:

    The Off-Button For Your Brain

    While it’s generally considered good to process feelings instead of putting them aside, the fact is that sometimes we have to hold it together while we do something, such that we can later have an emotional breakdown at a convenient time and place, instead of the supermarket or bank or office or airport or while entertaining houseguests or… etc.

    Today, though, we’re not putting things aside, for the most part (though we will get to that too).

    We’ll be dealing with shame, which is closely linked to the guilt we mentioned in that list there.

    See also: Reconsidering the Differences Between Shame and Guilt

    Shame’s purpose

    Shame’s purpose is to help us (as a community) avoid anti-social behavior for which we might be shamed, and thus exiled from the in-group. It helps us all function better together, which is how we thrive as a species.

    Shame, therefore, is often assumed to be something we can (and possibly should) use to ensure that we (ourselves and/or others) “do the right thing”.

    But there’s a catch…

    Shame only works negatively

    You may be thinking “well duh, it’s a negative emotion”, but this isn’t about negativity in the subjective sense, but rather, positive vs negative motivation:

    • Positive motivation: motivation that encourages us to do a given thing
    • Negative motivation: motivation that encourages us to specifically not do a given thing

    Shame is only useful as a negative motivation, i.e., encouraging us to specifically not do a given thing.

    Examples:

    • You cannot (in any way that sticks, at least) shame somebody into doing more housework.
    • You can, however, shame somebody out of drinking and driving.

    This distinction matters a lot when it comes to how we are with our children, or with our employees (or those placed under us in a management structure), or with people who otherwise look to us as leaders.

    It also matters when it comes to how we are with ourselves.

    Here’s a paper about this, by the way, with assorted real-world examples:

    The negative side of motivation: the role of shame

    From those examples, we can see that attempts to shame someone (including oneself) into doing something positive will generally not only fail, they will actively backfire, and people (including oneself) will often perform worse than pre-shaming.

    Looking inwards: healthy vs unhealthy shame

    Alcoholics Anonymous and similar programs use a degree of pro-social shame to help members abstain from the the act being shamed.

    Rather than the unhelpful shame of exiling a person from a group for doing a shameful thing, however, they take an approach of laying out the shame for all to see, feeling the worst of it and moving past it, which many report as being quite freeing emotionally while still [negatively] motivational to not use the substance in question in the future (and similar for activity-based addictions/compulsions, such as gambling, for example).

    As such, if you are trying to avoid doing a thing, shame can be a useful motivator. So by all means, if it’s appropriate to your goals, tell your friends/family about how you are now quitting this or that (be it an addiction, or just something generally unhealthy that you’d like to strike off your regular consumption/activity list).

    You will still be tempted! But the knowledge of the shame you would feel as a result will help keep you from straying into that temptation.

    If you are trying to do a thing, however, (even something thought of in a negative frame, such as “lose weight”), then shame is not helpful and you will do best to set it aside.

    You can shame yourself out of drinking sodas (if that’s your plan), but you can’t shame yourself into eating healthy meals. And even if your plan is just shaming yourself out of eating unhealthy food… Without a clear active positive replacement to focus on instead, all you’ll do there is give yourself an eating disorder. You’ll eat nothing when people are looking, and then either a) also eat next to nothing in private or else b) binge in secret, and feel terrible about yourself, neither of which are any good for you whatsoever.

    Similarly, you can shame yourself out of bed, but you can’t shame yourself into the gym:

    Is there positive in the negative? Understanding the role of guilt and shame in physical activity self-regulation

    Let it go

    There are some cases, especially those where shame has a large crossover with guilt, that it serves no purpose whatsoever, and is best processed and then put aside.

    For example, if you did something that you are ashamed of many years ago, and/or feel guilty about something that you did many years ago, but this is not an ongoing thing for you (i.e., it was a one-off bad decision, or a bad habit that have now long since dropped), then feeling shame and/or guilt about that does not benefit you or anyone else.

    As to how to process it and put it aside, if your thing harmed someone else, you could see if there’s a way to try to make amends (even if without confessing ill, such as by acting anonymously to benefit the person/group you harmed).

    And then, forgive yourself. Regardless of whether you feel like you deserve it. Make the useful choice, that better benefits you, and by extension those around you.

    If you are religious, you may find that of help here too. We’re a health science publication not a theological one, but for example: Buddhism preaches compassion including for oneself. Judaism preaches atonement. Christianity, absolution. For Islam, mercy is one of the holiest ideals of the religion, along with forgiveness. So while religion isn’t everyone’s thing, for those for whom it is, it can be an asset in this regard.

    For a more worldly approach:

    To Err Is Human; To Forgive, Healthy (Here’s How To Do It) ← this goes for when the forgiveness in question is for yourself, too—and we do write about that there (and how)!

    Take care!

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  • Luxurious Longevity Risotto

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Pearl barley is not only tasty and fiber-rich, but also, it contains propionic acid, which lowers cholesterol. The fiber content also lowers cholesterol too, of course, by the usual mechanism. The dish’s health benefits don’t end there, though; check out the science section at the end of the recipe!

    You will need

    • 2 cups pearl barley
    • 3 cups sliced chestnut mushrooms
    • 2 onions, finely chopped
    • 6 large leaves collard greens, shredded
    • ½ bulb garlic, finely chopped
    • 8 spring onions, sliced
    • 1½ quarts low-sodium vegetable stock
    • 2 tbsp nutritional yeast
    • 1 tbsp chia seeds
    • 1 tbsp black pepper, coarse ground
    • 1 tsp MSG or 2 tsp low-sodium salt
    • 1 tsp rosemary
    • 1 tsp thyme
    • Extra virgin olive oil, for cooking
    • Optional garnish: fresh basil leaves

    Method

    (we suggest you read everything at least once before doing anything)

    1) Heat a little oil in a large sauté pan; add the onions and garlic and cook for 5 minutes; add the mushrooms and cook for another 5 minutes.

    2) Add the pearl barley and a cup of the vegetable stock. Cook, stirring, until the liquid is nearly all absorbed, and add more stock every few minutes, as per any other risotto. You may or may not use all the stock you had ready. Pearl barley takes longer to cook than rice, so be patient—it’ll be worth the wait!

    Alternative: an alternative is to use a slow cooker, adding a quart of the stock at once and coming back about 4 hours later—thus, it’ll take a lot longer, but will require minimal/no supervision.

    3) When the pearl barley has softened, become pearl-like, and the dish is taking on a creamy texture, stir in the rest of the ingredients. Once the greens have softened, the dish is done, and it’s time to serve. Add the garnish if using one:

    Enjoy!

    Want to learn more?

    For those interested in some of the science of what we have going on today:

    Take care!

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  • Kidney Beans vs Fava Beans – Which is Healthier?

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Our Verdict

    When comparing kidney beans to fava beans, we picked the kidney beans.

    Why?

    It’s a simple and straightforward one today!

    The macronutrient profiles are mostly comparable, but kidney beans do have a little more protein and a little more fiber.

    In the category of vitamins, kidney beans have more of vitamins B1, B5, B6, B9, C, E, & K, while fava beans boast only more of vitamins B2 and B3. They are both equally good sources of choline, but the general weight of vitamins is very much in kidney beans’ favor, with a 7:2 lead, most of which have generous margins.

    When it comes to minerals, kidney beans have more iron, phosphorus, and potassium, while fava beans have more copper and selenium. They’re both equally good sources of other minerals they both contain. Still, a 3:2 victory for kidney beans on the mineral front.

    Adding up the moderate victory on macros, the strong victory on vitamins, and the slight victory on minerals, all in all makes for a clear win for kidney beans.

    Still, enjoy both! Diversity is healthy.

    Want to learn more?

    You might like to read:

    Chickpeas vs Black Beans – Which is Healthier?

    Take care!

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  • Gut-Healthy Sunset Soup

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    So-called for its gut-healthy ingredients, and its flavor profile being from the Maghreb (“Sunset”) region, the western half of the N. African coast.

    You will need

    • 1 can chickpeas (do not drain)
    • 1 cup low-sodium vegetable stock
    • 1 small onion, finely chopped
    • 1 carrot, finely chopped
    • 2 tbsp sauerkraut, drained and chopped (yes, it is already chopped, but we want it chopped smaller so it can disperse evenly in the soup)
    • 2 tbsp tomato paste
    • 1 tbsp harissa paste (adjust per your heat preference)
    • 1 tbsp ras el-hanout
    • ¼ bulb garlic, crushed
    • Juice of ½ lemon
    • ¼ tsp MSG or ½ tsp low-sodium salt
    • Extra virgin olive oil
    • Optional: herb garnish; we recommend cilantro or flat-leaf parsley

    Method

    (we suggest you read everything at least once before doing anything)

    1) Heat a little oil in a sauté pan or similar (something suitable for combination cooking, as we’ll be frying first and then adding liquids), and fry the onion and carrot until the onion is soft and translucent; about 5 minutes.

    2) Stir in the garlic, tomato paste, harissa paste, and ras el-hanout, and fry for a further 1 minute.

    3) Add the remaining ingredients* except the lemon juice. Bring to the boil and then simmer for 5 minutes.

    *So yes, this includes adding the “chickpea water” also called “aquafaba”; it adds flavor and also gut-healthy fiber in the form of oligosaccharides and resistant starches, which your gut microbiota can use to make short-chain fatty acids, which improve immune function and benefit the health in more ways than we can reasonably mention as a by-the-way in a recipe.

    4) Stir in the lemon juice, and serve, adding a herb garnish if you wish.

    Enjoy!

    Want to learn more?

    For those interested in some of the science of what we have going on today:

    Take care!

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  • Pistachios vs Cashews – Which is Healthier?

    10almonds is reader-supported. We may, at no cost to you, receive a portion of sales if you purchase a product through a link in this article.

    Our Verdict

    When comparing pistachios to cashews, we picked the pistachios.

    Why?

    In terms of macros, both are great sources of protein and healthy fats, and considered head-to-head:

    • pistachios have slightly more protein, but it’s close
    • pistachios have slightly more (health) fat, but it’s close
    • cashews have slightly more carbs, but it’s close
    • pistachios have a lot more fiber (more than 3x more!)

    All in all, both have a good macro balance, but pistachios win easily on account of the fiber, as well as the slight edge for protein and fats.

    When it comes to vitamins, pistachios have more of vitamins A, B1, B2, B3, B6, B9, C, & E.

    Cashews do have more vitamin B5, also called pantothenic acid, pantothenic literally meaning “from everywhere”. Guess what’s not a common deficiency to have!

    So pistachios win easily on vitamins, too.

    In the category of minerals, things are more balanced, though cashews have a slight edge. Pistachios have more notably more calcium and potassium, while cashews have notably more selenium, zinc, and magnesium.

    Both of these nuts have anti-inflammatory, anti-diabetic, and anti-cancer benefits, often from different phytochemicals, but with similar levels of usefulness.

    Taking everything into account, however, one nut comes out in the clear lead, mostly due to its much higher fiber content and better vitamin profile, and that’s the pistachios.

    Want to learn more?

    Check out:

    Why You Should Diversify Your Nuts

    Enjoy!

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  • Nutritional Profiles to Recipes

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    It’s Q&A Day at 10almonds!

    Have a question or a request? We love to hear from you!

    In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!

    As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!

    So, no question/request too big or small

    ❝I like the recipes. Most don’t seem to include nutritional profile. would lilke to see that. Macro/micro world…. Thank you❞

    We’re glad you’re enjoying them! There are a couple of reasons why we don’t, but the reasons can be aggregated into one (admittedly rare) concept: honesty

    To even try to give you these figures, we’d first need to use the metric system (or at least, a strictly mass-based system) which would likely not go well with our largely American readership, because “half a bulb of garlic, or more if you like”, and “1 cucumber” or “1 cup chopped carrot” could easily way half or twice as much, depending on the sizes of the vegetables or the chopping involved, and in the case of chopped vegetables measured by the cup, even the shape of the cup (because of geometry and the spaces left; it’s like Tetris in there). We can say “4 cups low-sodium broth” but we can’t say how much sodium is in your broth. And so on.

    And that’s without getting into the flexibility we offer with substitutions, often at a rate of several per recipe.

    We’d also need to strictly regulate your portion sizes for you, because we (with few exceptions, such as when they are a given number of burger patties, or a dessert-in-a-glass, etc) give you a recipe for a meal and leave it to you how you divide it and whether there’s leftovers.

    Same goes for things like “Extra virgin olive oil for frying”; a recipe could say to use “2 tbsp” but let’s face it, you’re going to use what you need to use, and that’s going to change based on the size of your pan, how quickly it’s absorbed into the specific ingredients that you got, which will change depending on how fresh they are, and things like that.

    By the time we’ve factored in your different kitchen equipment, how big your vegetables are, the many factors effecting how much oil you need, substitutions per recipe per making something dairy-free, or gluten-free, or nut-free, etc, how big your portion size is (we all know that “serves 4” is meaningless in reality)… Even an estimated average would be wildly misleading.

    So, in a sea of recipes saying “500 kcal per serving” from the same authors who say you can caramelize onions in 4–5 minutes “or until caramelized” and then use the 4–5 minutes figure for calculating the overall recipe time… We prefer to stay honest.

    PS: for any wondering, caramelizing onions takes closer to 45 minutes than 4–5 minutes, and again will depend on many factors, including the onions, how finely you chopped them, the size and surface of your pan, the fat you’re using, whether you add sugar, what kind, how much you stir them, the mood of your hob, and the phase of the moon. Under very favorable circumstances, it could conceivably be rushed in 20 minutes or so, but it could also take 60. Slow-cooking them (i.e. in a crock pot) over 3–4 hours is a surprisingly viable “cheat” option, by the way. It’ll take longer, obviously, but provided you plan in advance, they’ll be ready when you need them, and perfectly done (the same claim cannot be made if you budgeted 4–5 minutes because you trusted a wicked and deceitful author who wants to poop your party).

    Take care!

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