Slow Medicine

A compassionate approach to elderly care

Dennis McCullough

Dennis McCullough

Geriatrician and Faculty Member Dartmouth Medical School USA

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The patient's perspective is always, always central to the practice of Slow Medicine.

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1. What is the philosophy behind Slow Medicine?

The philosophy of slow medicine is based on the understanding that the best care and the best decisions about care come from careful, measured approaches to understanding an older person, their problems (medical and other), their values, their life and their living circumstances. This understanding arises through discussions and reflections by elders themselves along with their families (and other intimates--perhaps friends--which I term the "circle of concern") and their healthcare advisors.

2. In case of Slow Medicine, how would you define a successful outcome?

A successful outcome is one which reflects, on repeated re-assessment over time, the choices of the elder and his or her family. It is expected that there will be continuing periods where there may be uncertainty about these choices and choices must be re-visited as needed.

3. How can Slow Medicine help in solving the problems of elderly patients?

Slow medicine is not only a philosophy, but a practice. As such it requires time (not all at once) and very regular attention. In late life, the elder, the elder's circumstances and the problems the elder faces require that we not push for a fast decision, but allow time to help the elder; the family and health care providers achieve a deeper and truer understanding of what they must decide and provide. This is often not easy because it may require facing conflicts and differences of opinion and approach. It is expected that there will be continuing periods where there may be uncertainty about these choices and choices must be re-visited as needed.

4. What are the circumstances that prompt to choose slow medicine rather than conventional treatment?

For elders, slow medicine can be a gateway to conventional treatments, when that is the elder's choice. However, the practice of slow medicine may also lead to choices of "alternative medicine" or "traditional medicine" treatments or perhaps to "wait and watch" approaches that simply focus on symptom relief and comfort (and commitment to whatever approach is chosen).

5. It is said that Slow Medicine shares similarities with Hospice Care. In that case, what differentiates it from Hospice Care?

Slow medicine, palliative care and hospice care share the approach of paying a great deal of attention to the person and the person's specific problems and needs. However, where palliative care and hospice focus more on the very last days or weeks or months of care, slow medicine is practiced over years or perhaps, in some lives, a decade or more.

6. How can one assimilate patient's perspective in choosing Slow Medicine?

The patient's perspective is always, always central to the practice. Even if an elder is partially disabled, for example, by a stroke or some cognitive impairment, 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.

7. Do you think patient will be capable of taking a decision regarding what treatment he should undergo?

In those instances where an elder may clearly be unable to participate in making a decision, the burden falls to those (family, friends, health professionals) who have sought to understand the elder over the late life period.

8. What are your views on the ethical side of Slow Medicine?

Slow medicine blends the ethics of individuality (autonomy, benevolence, truthfulness, non-malfeasance) which focus on the empowered individual in making decisions with the ethics of character and commitment, which emphasize the importance and value of "staying with" an elder though all their ups and downs. This ethical approach, "commitment to the very end", in a partnership between elder, family and health care providers is presently less emphasized in our acute care-oriented medical systems.

9. Is the concept intended only for the elderly or for anyone who is at the end of life?

The philosophy and practice of slow medicine serve elders particularly well because we know that the journey of late life aging is more complicated than the middle life journey. Late life characteristically involves a more complex individual because of aging, a broader mix of problems and more complicated life circumstances for the elder and the family or "circle of concern". That said, many elements of both the philosophy and the practice of slow medicine can be applied helpfully for anyone nearing life's end.

10. Slow Medicine doesn't focus on saving the life of a patient; rather it focusses on quality of life and comfort of the patient. Then, is it proper to conclude that Slow Medicine is not an approach which can be practised in an emergency situation for an elderly?

Although there are some emergency situations where Slow Medicine might not be practiced to its full extent, there are always principles of Slow Medicine practice (communication with elder and family, kindness, doing one's best to make decisions based on as complete an understanding of an elder and their situation, maximising comfort) that still hold true. 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.

11. A patient in his 70s is advised to undergo an open heart surgery, only to prolong his life for few more years, of course, with all the risks that he faces during the first three months after surgery. What do you advise in such a situation?

Perhaps the most important part of this process is that there is a clear understanding of the real risks of this surgery and the potential benefits and the patient and his or her advisers have enough time to really think about them and discuss them, repeatedly, if necessary. Then, the answer usually emerges. For an otherwise healthy person, at the relatively young age of 70, the decision might be straightforward; for the patient over 80 with other problems, it could be a very difficult decision which should be explored over time. I have had patients decide both ways, which is perfectly in keeping with Slow Medicine. The important work here is to allow the patient to make the best decision possible for him or herself, aided by thoughtful and patient professional and family counsel.

12. How can the concept of slow medicine benefit the elderly patients a) who are suffering from life threatening ailments and b) who are not suffering from a life threatening ailment?

In both situations we should try to understand the situation, think together about the choices and allow as much time as is possible in the circumstances for a decision to be made. (This sometimes can run contrary to what the "system" wants most, which is a decision taken quickly to assure that high efficiency for the system occurs. Honouring efficiency over high quality decision-making is not what helps the patient most.)

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