Member Editorial Team Asian Hospital & Healthcare Management
Nature knows best. Less is more. These two are the thoughts surfacing recently in elderly care through the concept of Slow Medicine, pioneered by Dr Dennis McCullough, a geriatrician and a faculty member at Dartmouth Medical School and the author of My Mother, Your Mother Embracing "Slow Medicine": The Compassionate Approach to Caring for Your Aging Loved Ones. Slow Medicine is a less aggressive, family-centred and less expensive way of care that slots in all the requirements to be pursued for a quality end-of-life, especially for elderly patients. The elderly not only suffer due to ageing problems such as failing minds and bodies, but also because of an ill-equipped social healthcare system. The Slow Medicine model is rooted in the presumption that the choice of the elderly regarding their care should be appreciated.
The philosophy of Slow Medicine is to protect comfort of the patient rather than cure of an ailment. Slow Medicine shares with hospice care the approach of paying a great deal of attention to patients and their specific problems and needs. The difference, according to Dr McCullough, is that while hospice care focusses more on the very last days or weeks or months of care, Slow Medicine can be practiced over years or perhaps, in some cases, a decade or more. It is largely based on the belief that the best decisions about care come from a measured approach. This could involve understanding their problems, medical and others, their values, their life, their choices and their living circumstances. For elders, Slow Medicine could be a gateway to conventional treatments, provided it is of their choice.
Slow Medicine is a philosophy and also a practice. It demands time and regular attention. Many elements of the philosophy and the practice of Slow Medicine can be applied to help anyone approaching life's end. The philosophy and practice of Slow Medicine serves elders well because their journey of late life is more complicated than that of middle age. Factors like patient's age, strength and the severity of the ailment play a vital role in the practice of Slow Medicine.
If one were to define a 'successful outcome' in Slow Medicine, accomplishing a patient's preferences would be apt. According to Dr McCullough, "A successful outcome is one which reflects, on repeated re-assessment over time, the choices of the elder and his or her family."
The concept of Slow Medicine calls for the involvement of the patient and patient's family in taking a decision concerning the treatment that the patient should undergo. The principles of Slow Medicine include communication with elders, their family and doing one's best to take decisions based on complete understanding of the patient and the situation the patient is in and maximising his / her comfort. So, patient's consent and acceptance are vital to practicing Slow Medicine.
For example, a person in his seventies, suffering from an ailment may not be willing to undergo intensive medical treatments; rather he /she would be seeking a quality life for the time left over. Another patient, in the same condition might like to extend his / her life as much as possible from the available resuscitating therapies. Thus, the patient's perspective is always essential to the practice. Speaking about the patient's perspective, Dr McCullough says, "The patient's perspective must be sought through emotional and other physical responses-for instance, interest in eating, in relationships, etc. at this time of life."
The family and healthcare providers need to achieve a deeper and truer understanding of what they must decide and provide. Dr McCullough points out that this understanding arises through discussions and reflections by elders themselves along with their 'circle of concern'-families, other intimates and friends.
In the whole exercise, it is imperative that healthcare professionals must be open to the whole idea of Slow Medicine as they are the essential drivers for Slow Medicine. They should be ready to involve the patient and his /her family. They should discuss the condition of the patient, the available alternatives and the pros and cons of the alternatives. The milieu of the patient should be well known to the patient himself and his family.
In an effort to extend the life of the patient, family and physicians opt for intensive care, even if it means that the treatment could cause serious side effects. Some treatments hasten the downward course of patients' health leading to prolonged period of dependence. Most of the elderly are afraid of the side effects of intensive care. Dr McCullough advocates a less aggressive alternative in such situations. For example, a manual breast exam is preferable to a yearly mammogram for the very old and home tests for blood in the stool to the draining routine of a colonoscopy.
Slow Medicine encourages physicians to slow down when considering aggressive care that may cause high risks and limited rewards for the elderly. It is a return to the personal doctoring in an age of high-tech medicine. It edifies patients and families how to avoid hospitalisation and emergency room trips proposed for those with treatable ailments, not the usual downturn due to advanced age. And, the periphery of the treatment confines to the known surroundings of the patient, unlike the typical medical ambience which they resist the most.
Aggressive care in some cases saves life. A number of doctors opine that intensive care definitely prolongs life. This perception might not hold true in all cases. Still, mentioning only the cases of death would be biased and vice versa. Dr McCullough argues that "the decision to practice Slow Medicine can sometimes run contrary to what the 'system' wants most, which is a decision taken quickly to assure that high efficiency for the system occurs."
Slow Medicine is described as a less-expensive way of providing care. This gives rise to the ethical question of valuing human life. Furthermore, estimating the time left approximately considering the circumstances-which could differ from case to case-may prove the assessment wrong. So, choosing Slow Medicine is ultimately the choice of the patient and the patient's family. In that case, the question arises: how can the doctors allow the patient to take such a critical decision?
Regarding the ethical side of the concept, Dr McCullough says that Slow Medicine blends the ethics of individuality i.e. autonomy, benevolence, truthfulness and non-malfeasance which focus on the empowered individual in making decisions with the ethics of character and commitment. These ethics emphasise the importance and value of 'staying with' an elder though all the ups and downs. He comments, "This ethical approach, 'commitment to the very end', in a partnership between elder, family and healthcare providers is presently less emphasised in our acute care-oriented medical systems."
Every patient and his / her circle of concern would wish a long life, but at what cost and what kind of life would that be? These are the questions that cross through the minds of those involved in the process of decision-making.
The concept of Slow Medicine might not hold good in an emergency. But, Dr McCullough advocates the practice and states that though there are some emergency situations where Slow Medicine might not be practiced to its full extent, the principles of Slow Medicine practice still hold true. He says, "If one has practiced Slow Medicine along the way, emergencies as they occur are almost always better understood by the elder, the family and support persons and healthcare professionals."
Not only the 'circle of concern' of the patient, but physicians too tend to have a mindset of 'what all can be done, shall be done' to save and prolong the life of a patient at any cost. Their etiquette doesn't allow them to think beyond the physical existence of their loved ones. They would always like to try out all the available options to extend the life of the patient. Hence, Slow Medicine may not be an easy option.
All said, the idea of Slow Medicine is still foreign to many physicians who are proponents of aggressive treatments for patients' ailments. In the process, medical care has grown almost tantamount to technology-oriented care.
Resistance to change is common and it is the case with slow medicine too. But, as the patient population desiring this kind of care is increasing, the chances of sustainability of the concept are more. Time alone can prove how it nurtures the requirements of both the patients and the doctors.