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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Building Psychological Resilience (Without Undue Hardship)
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What’s The Worst That Could Happen?
When we talk about the five lifestyle factors that make the biggest difference to health, stress management would be a worthy addition as number six. We haven’t focused explicitly on that for a while, so let’s get ready to start the New Year on a good footing…
You’re not going to have a stress-free life
What a tender world that would be! Hopefully your stressors will be small and manageable, but rest assured, things will stress you.
And that’s key: “rest assured”. Know it now, prepare for it, and build resilience.
Sounds grim, doesn’t it? It doesn’t have to be, though.
When the forecast weather is cold and wet, you’re not afraid of it when you have a warm dry house. When the heating bill comes for that warm dry house, you’re not afraid of it when you have money to pay it. If you didn’t have the money and the warm dry house, the cold wet weather could be devastating to you.
The lesson here is: we can generally handle what we’re prepared for.
Negative visualization and the PNS
This is the opposite of what a lot of “think and grow rich”-style gurus would advise. And indeed, it’s not helpful to slide into anxious worrying.
If you do find yourself spiralling, here’s a tool for getting out of that spiral:
RAIN: an intervention for dealing with difficult emotions
For now, however, we’re going to practice Radical Acceptance.
First, some biology: you may be aware that your Central Nervous System (CNS) branches into the Sympathetic Nervous System (SNS) and the Parasympathetic Nervous System (PNS).
The PNS is the part that cues our body to relax, and suppresses our fight/flight response. We’re going to activate it.
Activating the PNS is easy for most people in comfortable circumstances (e.g., you are not currently exposed to stressful stimuli). It may well be activated already, and if it’s not, a few deep breaths is usually all it takes.
If you’d like a quick and easy Mindfulness-Based Stress Reduction (MBSR) technique, here you go:
No-Frills, Evidence-Based Mindfulness
Activating the PNS is hard for most people in difficult circumstances (e.g., you either are currently exposed to stressful stimuli, or you are in one of the emotional spirals we discussed earlier).
However, we can trick our bodies and brains by—when we are safe and unstressed—practicing imagining those stressful stimuli. Taking a moment to not just imagine it experientially, but immersively. This, in CBT and DBT, is the modern equivalent to the old samurai who simply accepted, before battle, that they were already dead—and thus went into battle with zero fear of death.
A less drastic example is the zen master who had a favorite teacup, and feared it would get broken. So he would tell himself “the cup is already broken”. One day, it actually broke, and he simply smiled ruefully and said “Of course”.
How this ties together: practice the mindfulness-based stress reduction we linked above, while imagining the things that do/would stress you the most.
Since it’s just imagination, this is a little easier than when the thing is actually happening. Practicing this way means that when and if the thing actually happens (an unfortunate diagnosis, a financial reversal, whatever it may be), our CNS is already well-trained to respond to stress with a dose of PNS-induced calm.
You can also leverage hormesis, a beneficial aspect of (in this case, optional and chosen by you) acute stress:
Dr. Elissa Epel | The Stress Prescription
Psychological resilience training
This (learned!) ability to respond to stress in an adaptive fashion (without maladaptive coping strategies such as unhelpful behavioral reactivity and/or substance use) is a key part of what in psychology is called resilience:
And yes, the CBT/DBT/MBSR methods we’ve been giving you are the evidence-based gold standard.
Only the best for 10almonds subscribers! 😎
❝That was helpful, but not cheery; can we finish the year on a cheerier note?❞
We can indeed:
How To Get Your Brain On A More Positive Track (Without Toxic Positivity)
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What Your Skin Texture Says About Your Health
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Dr. Andrea Suarez, dermatologist, shows us what to watch out for:
To the touch
We (and videos that we share here!) talk a lot about the appearance of various skin conditions, but skin texture is more about the physical feel and surface quality of your skin—including roughness, flaking, bumpy follicular changes, thickening, thinning, crepey fragility, or a doughy or hardened feel—and while many changes are harmless, certain patterns in the certain contexts can be signs of disease, including of the kind that are more than skin-deep.
What different skin textures mean:
- Persistent roughness and flaking: ongoing dry, rough, flaky skin is usually due to barrier dysfunction from overexfoliation, harsh cleansers, hot water, low humidity, or aging, but in some cases is because of hypothyroidism or an essential fatty acid deficiency.
- Velvety dark thickened skin: velvety, dark, thickened plaques in skin folds such as the neck or underarms suggest acanthosis nigricans, a sign of insulin resistance commonly associated with type 2 diabetes, that can appear before blood sugar levels cross diagnostic thresholds.
- Sudden adult acne or oily skin: new-onset oily skin and acne in adulthood may relate to hormonal shifts such as polycystic ovary syndrome (PCOS), hyperandrogenism, perimenopause, or chronic stress affecting cortisol, especially if accompanied by irregular periods, hair changes, or metabolic warning signs.
- Waxy puffy doughy skin: thick, swollen, doughy skin—sometimes progressing to myxedema with mucopolysaccharide buildup—alongside fatigue, cold intolerance, and hair thinning suggests hypothyroidism and often improves with appropriate treatment.
- Fragile crepey easily bruised skin: thin, fragile, crepey skin known as dermatoporosis is most commonly due to cumulative sun damage but can also result from chronic glucocorticoid use, prolonged topical steroid application, or malnutrition.
- Keratosis pilaris: rough follicular bumps (keratosis pilaris) are common and often genetic, but can also be associated with atopic dermatitis, asthma, allergic rhinitis, ichthyosis vulgaris, type 2 diabetes, insulin resistance, Down syndrome, or (rarely) certain medications.
- Phrynoderma: larger, hyperpigmented, hard follicular bumps called phrynoderma are generally linked to vitamin A deficiency and can occur with malabsorption, chronic illness, or severe dietary restriction.
- Skin tags: a few skin tags are common and harmless, but numerous tags—especially alongside acanthosis nigricans—can be a sign of insulin resistance due to elevated insulin-like growth factor stimulating epidermal proliferation (i.e. too many skin cells being made in one place).
- Scleredema: non-pitting, woody skin thickening on the upper back and neck is called scleredema has three variants (post-streptococcal, monoclonal gammopathy–associated, and diabeticorum); the diabetic form most often seen in long-standing, poorly controlled diabetes.
Some quick myths to bust, while we’re at it: textural changes don’t indicate toxin buildup, liver failure, candida overgrowth, or leaky gut, as these claims are common online myths often used to market unnecessary products.
For more on all of this plus visual demonstrations, enjoy:
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Bridging The Generation Gap Over The Holidays
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Often seen as a time for family connection, this same holiday period is often experienced as a time of family tension. But it doesn’t have to be that way!
Hopefully this will be of benefit to readers of all ages, but we’re going to write with the largest age-group of our readership, which is people who are most likely to have Gen-Z grandkids.
why are we writing about this?
Not only are health and happiness closely linked, and not only is mental health also just health, but… In terms of the healthy longevity secrets of the “Blue Zones”, strong intergenerational connections are usually a feature.
First, the obvious:
Any holiday tensions, of course, don’t usually start with grandkids, and are more likely amongst the adults, but some points of friction can be the same:
- Differences of opinion on political/social/economic issues
- Difference of opinion on parenting/dating choices
- Differences of opinion on life priorities
And yes, by the way, that includes even young teens (and perhaps younger) having opinions on these things—we are living in an information age, and this does mean a lot of information is a lot more accessible than it used to be, including for kids. Problems (at all ages) may occur when someone is only really exposed to views from within a certain “bias bubble”, but for better or worse, most people will have an opinion on most well-known things.
As a general rule of thumb, all of these differences of opinion can be shelved if (and only if) those involved seek to avoid conflict. And while age is no guarantee of maturity, often it’ll be the older person(s) in the strongest position to redirect things. So, have a stack of “safe” topics up your sleeve.
Bonus: you can also have non-conversational distractions up your sleeve! These may be kitchen-related, for example (time to produce something distracting, or if the nascent conflict was only between you and one other person, time to go check on something, thus removing yourself from the situation).
Next, about “family time” and technology
It can be tempting to try to have a “phones away” rule, but this will tend to only exacerbate a younger person’s withdrawal.
Better: ask (with a tone of cheerful curiosity, not accusation) about what captures their attention so. Ask about their favorite YouTubers or TikTokers or whatever it is that it is for them. Learn about that Subreddit.
Or maybe (more likely for Millennials) they were following what is going on in the world via social media, which takes on an intermediary role for the delivery of world news. Hopefully this won’t run into the differences of opinion that we mentioned up top, but it could also be a perfectly good avenue of conversation, and maybe there’s more common ground than you might expect.
Meanwhile, if you’re the older generation present, chances are your own social media use is more about the human element. That’s great, but watch out:
A common faux pas is taking pictures without asking, let alone posting them online without asking. For many people this may seem an odd thing to object to, but generationally speaking, the younger someone is (down to the upper single digits, anyway) the more likely they might feel strongly about this. So, ask first.
The reason, by the way, is that in this age of digital hypervisibility, what we choose to share online can be a deeply personal thing. And, say what you will about the pros or cons of someone carefully curating an image of how they wish to be seen, shortcutting through that for them with a candid photo posted on Facebook will not endear you to them, even if you can’t see anything wrong with the photo in question, for example.
See also: Make Social Media Work For Your Mental Health
Show an interest, but don’t interrogate
This one doesn’t take too much explanation. If people want to share about their lives, they’ll need only the smallest nudge to do so. If someone passes up an opportunity to talk about something you showed an interest in, chances are they have their own reasons for not wanting to talk about it. This might be hurtful if you feel like they’re keeping you out of their life, but the best way to get them to talk to you is just to be a good listener—not an interrogator that they have to dodge.
For some powerful tools on this, see: Listening, Better
Lastly, if things aren’t so good…
43% of people are currently experiencing some sort of familial estrangement, so if that’s you, you’re not on your own.
Sometimes, it really is too late to fix things, but sometimes it isn’t; we put together a guide that might help:
Family Estrangement & How To Fix It
Take care!
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Lower Your Cortisol! (Here’s Why & How)
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Cortisol, or “the stress hormone” to its friends, is produced by your adrenal glands, and is generally considered “not fun”.
It does serve a purpose, of course, just like almost everything else our body does. It serves as part of the “fight or flight” response, for example, and helps you to wake up in the morning.
While you do need some cortisol (and a small percentage of people have too little), most of us have too much.
Why? Simply put, modern life is not what 200,000* years of human evolution prepared us for:
- Agriculture (which allowed us to settle down and cease being nomadic) happened during the last 6% of those 200,000 years.
- The Industrial Revolution and the onset of modern capitalism happened during only during the last 0.1% of those 200,000 years.
*the 200,000 years figure is conservative and doesn’t take into account the 200,000,000 years of pre-hominid mammalian evolution. Doing so, on the basis of the mammalian brain & physiology being what’s important here, means our modern stressors have been around for <0.0001% of the time we have.
So guess what, our bodies haven’t caught up. As far as our bodies are concerned, we are supposed to be enjoying the sunshine of grassy plains and the shade of woodland while eating fruit.
- When the alarm clock goes off, our body panics and prepares us to either flee or help fight the predator, because why else would we have been woken so?
- When we have a pressing deadline for work, our brain processes this as “if we don’t do this, we will literally starve and die”.
- When people are upset or angry with us, there’s a part of our brain that fears exile from the tribe and resultant death.
…and so on.
Health Risks of High Cortisol
The long-term stressors are the biggest issue for health. Unless you have a heart condition or other relevant health problem, almost anyone can weather a brief unpleasant surprise. But if something persists? That prompts the body to try to protect you, bless it. The body’s attempts backfire, because…
- One way it does this by making sure to save as much food as possible in the form of body fat
- It’ll also increase your appetite, to make sure you eat anything you can while you still can
- It additionally tries to protect you by keeping you on the brink of fight-or-flight readiness, e.g:
- High blood pressure
- High blood sugar levels
- Rapid mood changes—gotta be able to do those heel-turns as necessary and react quickly to any possible threat!
Suffice it to say, these things are not good for your long-term health.
That’s the “Why”—now here’s the “How”:
Lowering your cortisol levels mostly means lowering your stress and/or lowering your stress response. We previously gave some powerful tools for lowering anxiety, which for these purposes amounts to the same thing.
However, we can also make nutritional and lifestyle changes that will reduce our cortisol levels, for example:
- Reduce (ideally: eliminate from your lifestyle) caffeine
- Reduce (ideally: eliminate from your lifestyle) alcohol
- Yes, really. While many understandably turn to alcohol specifically to help manage stress, it only makes it worse long-term.
- Additionally, alcohol directly stimulates cortisol production, counterintuitive as that may be.
Read: Alcohol, Aging, and the Stress Response ← full article (with 37 sources of its own) from the NYMC covering how alcohol stimulates cortisol production and what that means for us
As well as reductions/eliminations, are some things you can add into your lifestyle that will help!
We’ve written previously about some:
Read: Ashwagandha / Read: L-Theanine / Read: CBD Oil
Other things include, no surprises here:
- The Mediterranean diet (nutritious and delicious): https://10almonds.com/mediterranean-diet
- Get 7–9 hours (good quality!) sleep per night: https://10almonds.com/time-pillow-talk
- Get regular exercise (the regularity matters most!): https://10almonds.com/keep-on-keeping-on
Progressive Relaxation
We’ll give this one its own section because we’ve not talked about it before. Maybe you’re familiar. If not, then in a nutshell: progressive relaxation means progressively tensing and then relaxing each part of your body in turn.
Why does this work? Part of it is just a physical trick involving biofeedback and the natural function of muscles to contract and relax in turn, but the other part is even cleverer:
It basically tricks the most primitive part of your brain, the limbic system, into thinking you had a fight and won, telling it “thank you very much for the cortisol but we don’t need it anymore”.
Take a Hike! Or a Stroll… You Do You!
Last but not least: go connect with your roots. Spend time in the park, or at least the garden. Have a picnic, if the weather suits. Go somewhere you can spend time around leafy green things under a blue sky (we realize the blue sky may be subject to availability in some locations, but do what you can!).
Remember also: just as your body’s responses will be tricked by the alarm clock or the housework, they will also be easily tricked by blue and green stuff around you. If a sunny garden isn’t available in your location, a picture of one as your desktop background is the next best thing.
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How To Actually Get Abs (10 Annoying Tips That Work!)
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Cori Lefkowith, of “Strong At Any Age”, advises…
The method
It may not be fun, but here’s what she finds works:
- Be boring: stick to a simple, repetitive diet to track progress easily, and make hitting macros simpler.
- Cut back on protein bars: processed protein bars are calorie-dense but not filling (due to their small volume), so limit them, especially when trying to get lean.
- Stop daily fluctuations: she advises to be precise with macros and calories daily, not just weekly, to see consistent results.
- Focus on fiber: aim for 25–30g of fiber daily to improve gut health, reduce cravings, and maintain health while cutting fat.
- Get 30–40g of protein per meal: ensure each meal has enough protein to fuel muscle growth and support overall body function.
- Prioritize carbs around workouts: eat carbs before and after training to fuel performance, aid muscle repair, and maintain lean mass.
- Take diet breaks: incorporate 1–2 week maintenance phases to prevent metabolic adaptation, maintain muscle, and thus stay consistent in the long-term.
- Be careful with fat burners & preworkout: these can harm sleep, recovery, and long-term fat loss; opt for natural dietary energy sources instead.
- Don’t set-and-forget: regularly assess and adjust your diet and macros as your body and lifestyle change.
- “Suck it up, buttercup”: fat loss requires persistence, discipline, and pushing through tough moments when you feel like quitting.
For more on all of this, enjoy:
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You might also like:
Is A Visible Six-Pack Obtainable Regardless Of Genetic Predisposition?
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Lobster vs Crab – Which is Healthier?
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Our Verdict
When comparing lobster to crab, we picked the crab.
Why?
Generally speaking, most seafood is healthy in moderation (assuming it’s well-prepared, not poisonous, and you don’t have an allergy), and for most people, these two sea creatures are indeed considered a reasonable part of a healthy balanced diet.
In terms of macros, they’re comparable in protein, and technically crab has about 2x the fat, but in both cases it’s next to nothing, so 2x almost nothing is still almost nothing. And, if we break down the lipids profiles, crab has a sufficiently smaller percentage of saturated fat (compared to monounsaturated and polyunsaturated), that crab actually has less saturated fat than lobster. In balance, the category of macros is either a tie or a slight win for crab, depending on your personal priorities.
When it comes to vitamins, crab wins easily with more of vitamins A, B1, B2, B6, B9, B12, and C, in most cases by considerable margins (we’re talking multiples of what lobster has). Lobster, meanwhile, has more of vitamin B3 (tiny margin) and vitamin B5 (pantothenic acid, as in, the vitamin that’s in basically everything edible, and thus almost impossible to be deficient in unless literally starving).
The minerals scene is more balanced; lobster has more calcium, copper, manganese, and selenium, while crab has more iron, magnesium, phosphorus, potassium, and zinc. The margins are comparable from one creature to another, so all in all the 4:5 score means a modest win for crab.
Both of these creatures are good sources of omega-3 fatty acids, but crab is better.
Lobster and crab are both somewhat high in cholesterol, but crab is the relatively lower of the two.
In short: for most people most of the time, both are fine to enjoy in moderation, but if picking one, crab is the healthier by most metrics.
Want to learn more?
You might like to read:
Shrimp vs Caviar – Which is Healthier?
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