Ballroom Dancing, Delight and Dementia Prevention

Dancing With Heart

Dancing With Heart

Say what?  You mean that social dancing makes you smarter?  Why yes, smarter in the sense of maintaining what we’ve got as we grow older.   I liked this article entitled Use It or Lose It: Dancing Makes You Smarter by Richard Powers.  Dancing might seem like a frivolous activity, but in fact it is fabulous means for the brain to integrate several of its functions at once.  These functions include kinesthetic, musical, emotional and rational.  Ballroom dance is what I am focusing on because I am pretty new to it, but other forms of dance are great as well.  We’re talking about improving mental acuity by creating new pathways.  Isn’t that what we’re after in this whole longevity-obsessed, youth-adoring culture of ours?  We don’t really want to do the same exact thing (like crossword puzzles or Sudoku) for the rest of our lives do we? At least a few of us are here to enjoy what we’ve got – I’m pretty certain about that.   At least one centenarian has attributed her longevity to ballroom dancing.  Another dancing centenarian observed that ballroom dance has kept him young at heart.  Finally, there is the 94 year old yogini (a female yoga practitioner) who observed yoga is the dance of the spirit. Ballroom dancing is the physical awareness that comes from the joy within us.  I wholeheartedly agree with her about ballroom dance and joy.  I can’t imagine having an awful time on a dance floor!

Not that it isn’t fun to engage in your favorite mental or physical activities, like reading, playing golf or working puzzles, but frequent dancing was #1 in a study published in the New England Journal of Medicine about recreational activities and mental acuity in aging and reducing the risk of dementia.  Here’s another article about “waltzing your way to longevity and better health.”

You might think that ballroom dancing is predictable patterns . . .  that is, if you had never really learned how to ballroom dance!  Ballroom dance is a form of human communication that is variable and unpredictable, in addition to being highly personalized.  Yes, you may think of the highly choreographed Fred and Ginger dances, but most ballroom dance is “freestyle” meaning it is not choreographed or predictable.

Okay, I should mention this post is in honor of my all day activity last Saturday at the Marriott City Center grand ballroom – the Arthur Murray Colorado Showcase dance competition.  Yours truly danced a total of nine dances including a waltz solo, along with fox trot, tango, merengue, rumba and a few more. This is the delight part of the post!  I performed (with my partner) a choreographed solo and the rest of the dances were “freestyle” meaning that leader and follower have to pay attention to each other’s cues and make split second decisions. . . . together!  Social dancing (like at my Arthur Murray studio in Lakewood) means you have different partners, which means different communication, leading, following and dancing styles.  Yes, it keeps you on your toes!

Last week I received my latest issue of Scientific American Mind and it has an article entitled The Healing Power of Music, which discusses new therapies that are using rhythm, melody and beat to help people with brain disorders and injuries to recover language, hearing motion and emotion.  Music engages people because it is enjoyable, it makes us happy (read: it initiates changes in the distribution of neurochemicals that can improve mood and calm us, allowing for healing) permits synchronization (by tapping along) and it is, of course – social, meaning it can be a collective and not simply an individual experience.   Perhaps this is another key to ballroom dance’s reputation as a means of promoting joy and social connection to others.

One last thing, I promised my dear friend Beth, who got me to try out dancing at her studio a few months back (and I have been hooked since), that I would participate in her fund-raising effort for Team Not For Sale, by making donations for my solo and freestyle dances at the Colorado Showcase as she was to planning to make for her own dances.  Team Not for Sale has many professional sports figures (Beth is a huge baseball fan, while I am not a fan of any sports team . . . ) but its focus is to raise awareness of human trafficking, slavery and exploitation and to prepare people affected by exploitation to enter the workforce.  It is a worldwide problem and nearly all the victims of sex trafficking are women and girls.  I think in this respect dance is a form of freedom, of freedom to express our joy, to raise it and share it with others, while simultaneously recognizing that many of us do not have such opportunities to freely express such joy.

 ©Barbara Cashman  2015   www.DenverElderLaw.org

 

Physical Intimacy and Elders or . . . . Sex in the Nursing Home

Denver Botanic Gardens July 2014

Denver Botanic Gardens July 2014

Deep within the youth-glorifying part of our culture, right next to the expansive real estate of death denial, is a controversial aspect of our humanity subject to the aging process – the physical intimacy-denying part of our collective conception of what is “appropriate” behavior for elders. It might also be part of ageism, but I’m not too sure about that.  Last month I attended a continuing legal education program put on by two of my colleagues – Ayo Labode and Mary Catherine Rabbitt.  One of Mary Catherine’s short topics was intimacy between residents of skilled nursing facilities.  In fact, the topic for this week’s elder law section CLE program at our monthly meeting at the Colorado Bar Association offices is “sexual expression in long term care.”  I know it will be well-attended!  I thought it was time to bring out this draft of a post I wrote some months back and was waiting to finish.

I recall Roger Angell’s New Yorker article I featured in a previous post entitled “This Old Man.”  In fact, I will include a quote from it here:

More love; more closeness; more sex and romance. Bring it back, no matter what, no matter how old we are. This fervent cry of ours has been certified by Simone de Beauvoir and Alice Munro and Laurence Olivier and any number of remarried or recoupled ancient classmates of ours. Laurence Olivier? I’m thinking of what he says somewhere in an interview: “Inside, we’re all seventeen, with red lips.”

Many of us in my field of elder law are familiar with situations that run the gamut of this human need for intimacy that includes sexual expression in old age – whether it is someone’s 85-year-old mother who found her new husband through online dating or is the commonly occurring but not well-accepted sexual intimacy between residents in a skilled nursing or assisted living facility.  We are charting a new course for elderhood here!  Here’s a link to an article about sexually transmitted diseases and folks enrolled in Medicare.  The baby boomers have much to learn from our parents’ generation and many believe that with the burgeoning number of boomer elders, this issue is likely to remain a hot button for many years to come.  But let’s face it, in the context of elderhood, few are comfortable with talking about sex or death.

Intimacy is a basic human need for many of us that continues regardless of age and living situation.  As the boomers age and the number of assisted living and SNF residents continue to grow, this will be a challenge that will need to be addressed on a strategic or big picture level.  Here’s a short piece written by a long term care Ombudsman on this topic.  There are many sources from the psychological and medical community which address the benefits of intimacy for elders living in an institutionalized setting.  A newsletter for Geriatric Care Managers featured a story on Sex in the Nursing Home.

Beyond the ageist factors that can tend to make elders invisible and simply “too old” to merit sexual expression, the mental capacity issue here looms in the background in at least some segments of the population who are residents in long term care or similar type living arrangements.  Who determines the level of capacity required for consensual sex and what are the boundaries?  Australian authors Laura Tarzia and two others published a paper entitled “Dementia, sexuality and consent in residential aged care facilities.  You can read it here.

A related issue involving consent concerns sexual abuse, but most of those cases involve assault by staffers on residents, although there has been well-founded concern raised when registered sex offenders are residents of long term care facilities, particularly when residents and families are not notified due to the fact that there is typically no notification requirement, but some states are working on ways of keeping such residents out of the “general population” at a skilled nursing facility.

If you think it’s not so controversial, read this post about staff members at an Iowa nursing home who lost their jobs in the wake of sexual relationship between two residents with dementia in 2009.  A recent blogpost on this topic features a video clip from a doctor addressing some of the difficult issues.  The sex taboo in SNFs is going to have to change.  Read an interesting post here by an assisted living staffer about the large number of sexually-active elders and elders’ rights to “sexual self-determination.”

I will be writing more on this topic and I anticipate it will becoming much more mainstream as we look more closely at many of our ideas about how we age.  Stay tuned.

©Barbara Cashman  2015   www.DenverElderLaw.org

Part II: Is Physician Assisted Death Coming to Colorado? (Not this year)

At the Chatfield Wetlands

At the Chatfield Wetlands

This is the continuation of my previous post about the Colorado House of Representative bill on physician assisted death, on the topic “Concerning a Terminally Ill Individual’s Freedom to Make End-of-Life Decisions, a/k/a the “Colorado Death with Dignity Act.”

If you’re curious about the debate in other parts of the world, here’s a link to a recent article in The Guardian.  And here’s a New York Times article from last year on the topic of “aid in dying,” as there are variety of names for what is collectively physician assisted death (PAD).  Well, back to the Colorado bill.

I will continue in this post with some of the concerns I have with the proposed legislation – from the standpoint of what is in the bill (terminology) and how it works (philosophy).  I have difficulties with the term “informed decision” and how it relates to the principle of informed consent – the process for getting permission for a patient prior to conducting a healthcare intervention.  Based on the definition in (7) of section 25-47-102, this “informed decision” doesn’t look like informed consent.  What is it that the doctor advising a patient about this life-ending process must advise their patient? Some of it is informed consent, but it seems to be bigger than that and only for purposes of this legislation.  This is vague and troublesome indeed.   Can’t we just call it informed consent for ending one’s life? Will that agitate the medical community? This is another unsaid conflict that should not go unnoticed in this bill.

One of the stated concerns relating to a person’s capacity in this bill is that the person be “capable” and not otherwise suffering from a depression-impaired ability to make an informed decision.  This bill seeks to pigeonhole diagnoses, to impose clarity in another rather gray area.  There are some terminal diseases, like Parkinson’s, which often have a psychological or psychiatric component that cannot be easily extracted from the disease itself.  In my experience, I have seen disability insurers seeking to exclude from coverage a person with a diagnosis of Parkinson’s disease because those persons often also have a diagnosis of depression that accompanies Parkinson’s.  I use this by way of example only, to assert that it is not at all simple for any health care provider to extract a psychiatric or psychological disorder such as depression (as stated in the bill at section 25-47-107) that accompanies a diagnosis or prognosis or course of disease progression from that which impairs one’s ability to make an informed decision.  There is a psychosocial component to many terminal illnesses, you can read more here about treating depression in advanced cancer.

This goes back to the rather slippery nature of the informed decision versus informed consent distinction.  The medical-technological focus on dying in this bill is on death not as a natural process of life but as a medical problem.  I believe this is in large part what perpetuates the avoidance and the denial of death in our culture.  Using emotional restraint, facing death stoically and by deciding bravely to “assert control” to foreshorten any disturbing developments of the disease progression or any needless suffering are all bureaucratic way of making death “ordinary” in the sense it happens to us all.  This extends the social isolation of the dying person, making their suffering worse, a dying person is in this way of thinking simply a useless reject of a person.  The “brave choice” of a person in this context converts the life-ending decision into a glorified act of autonomy.  The individual’s decision is theirs alone.  This approach of physician-assisted death (PAD) stands in contrast to the family unit or community based models of hospice and palliative care, which seek to lessen pain, maximize quality of life for the dying and hold those persons in their identities.  In this respect, PAD becomes a means of the individual’s attempt to fight back against the ignominy of illness, of life-robbing disease which compromises one’s social identity.  I don’t buy it!

Another problematic inclusion is the family notification provision in section 25-47-109.  I am not sure why this in the bill. I don’t really understand what its point is, it seems to be about the doctor recommending some kind of reconciliation if the patient is estranged from his family, which may have nothing to do with patient’s decision to end his life with assistance from a doctor. It seems to hint at including the family in a person’s decision, but it is a feeble attempt at such.

The last point I will raise specifically about this bill, is its reference in section 25-47-103: “Individuals permitted to request life-ending medication”

(1) that an individual is qualified to make such request for life-ending medication if the individual is (a) an adult; (b) is capable; (c) is a Colorado resident; (d) is suffering from a terminal illness. . . and (e) has voluntarily expressed his or her wish to die.  

(2) “A person does not qualify under this article solely because of age or disability.”

This seems to be saying in (1) that those whose quality of life was fully autonomous and who suffer from a terminal disease which implicates that autonomy, by its diminution by degrees, or by an aversion to “suffering” or one’s inability to “control” it – those are the persons who are likely to avail themselves of the life-ending process, for whom this legislation is designed.  It implies in (2) that the disabled and elders who are perceived as “dependent” on others or with some diminished quality of life and whose lives are often pitied by the “young,” able-bodied and independent, would otherwise qualify for life-ending medications based on some perception of the disabled or elder’s quality of life.  I do not imply here that there is any unified voice of the disabled community or of elders voicing an opinion about this, I find this language offensive.

More indifference to the suffering and social isolation of the terminally ill and dying persons is not the answer.  To hasten the demise under the banner of the socially acceptable terms of “autonomy” and “dignity” is not a way of de-medicalizing or re-humanizing the dying process, rather the PAD is a feeble attempt to make death “less threatening” and I just don’t buy it.  The lack of ritual around dying, along with the absence of any recognizable system of meaning around dying and death has resulted in the further isolation and stigmatization  of the terminally ill or dying person.  This bill to allow PAD does not promote death with dignity, rather it offers the socially acceptable perpetuation of the illusion that death con be contained and controlled and need not be “disturbing.”

Update from Friday Feb. 6th’s evening legislative activity: The House Health Committee voted to kill this bill (HB 15-1135) on an 8-5 vote.  Two of the Democrats on the committee joined the Republicans to oppose it.  

©Barbara Cashman  2015   www.DenverElderLaw.org

Is Physician Assisted Death Coming to Colorado?

The Road Only Appears to End

The Road Only Appears to End

I recently looked at the Colorado House bill 15-1135 on the topic “Terminally Ill Individuals End-of-Life Decisions, a/k/a the “Colorado Death with Dignity Act.”  You can read the January 9, 2015 draft here.  There are, as of February 2, 2015, two senate sponsors and an updated version of the bill.  My first challenge with this bill is the how it is marketed – the idea that “death with dignity” can only be accomplished by one’s own hand with the assistance of a physician.  If this sounds provocative, it is – but it implies that the disease process part of a person’s life or the dying from the insult of disease is somehow not otherwise dignified.  Here’s a link to a Jan. 27, 2015 Denver Post article about this proposed legislation, and a link to another appearing on Feb. 1,2015.  This is the first post in a series.

I find myself in the same camp as the hospice and palliative care community as far as the title is concerned.  The idea that the way to die “with dignity” is through physician assisted death by one’s own hand is offensive.  End-of-life decision making is an area in which Colorado residents and patients have many resources.  The title implies otherwise and is simplistic and misleading.  I also find the bill’s descriptions of “alternatives” such as hospice care and palliative care are confusing and misleading. I am unable to come up with a scenario in which physician aided death is a true “alternative” to these.  I think in all cases with which I am familiar, patients have already been under the care of a doctor for hospice or palliative care.  The physician aided dying is more of an “end of the line” complement of sorts to these well-established, even if not widely-recognized forms of medical care.  The primary distinction between these, what makes physician assisted death (PAD) a real alternative to hospice and palliative care is that physician assisted death is not a natural death as the result of a disease process.  PAD represents a premature death, hastened by a number of different perceptions and choices about what one’s life is for as well as one’s own ideas about loss of autonomy amounting to loss of dignity and as needless suffering.  In this respect, terminal disease is a failure of one’s ability to control an outcome, and fear of a change in one’s identity in the world due to a change in one’s relationship to others.  I think physician assisted death further isolates and marginalizes people and the dying in particular.  It is in the time of weakness and vulnerability when we need each other.  This is dignity, what it means to be human.  Here’s a link to a recetly posted youtube by Jean Vanier, of L’Arche Internationale, speaking to the English House of Lords, on why the strong need the weak.  I think it easily translates into why the healthy and living need the sick and dying.

Another big distinction between PAD and hospice and/or palliative care is the philosophical problem of distinguishing physician assisted dying from medical care.  That difficult distinction crops up throughout the bill with the challenge of identifying informed consent in a way that is a major departure from its history.  The Greek roots of the word “euthanasia” mean “easy death.”  There are different types of euthanasia, as described in this abstract from pubmed.gov and the moral dilemma presented by its practice is ancient.  Euthanasia is premised on the ending of life and may be voluntary or involuntary and active or passive.  Suffice it to say there is no bright line in this arena, only slippery slopes leading in both directions!

One of those slopes I find particularly troubling concerns the definition of “capable” in the bill.  This is defined in section 25-47-102(3) and it is overly broad.  We don’t have any context for this meaning of “capable” – capable to do what exactly?  This is the touchstone for capacity determinations in the field of estate and elder law.   Is this definition of “capable” for giving informed consent for health care purposes or something different?  I conclude it must be the latter, so the lack of a definition is a big problem.  Would a court need to determine someone “capable” to make a decision under this statute?  Under guardianship law, only those who have had a guardianship lifted are “adjudicated” as “capable.”  All adults, persons aged eighteen and older, are presumed by the law to have capacity.  “Capable” as used in this draft bill is too vague. Another part of the bill (the consulting physician confirmation of 25-47-106(1)(c) refers to this trifecta: requiring that the individual be capable, acting voluntarily and has made an informed decision.  I find this safety net here very interesting – what it is designed to protect against . . .  well that is not discussed anywhere, it is left unsaid.

The absence of any aspect of spirituality is telling – but there are those who think that leaving out the spiritual aspects and the soul-learning of the dying process are too hot not to handle.  See M. Scott Peck, “The Denial of the Soul: Spiritual and Medical Perspectives on Euthanasia and Mortality” (1997: Harmony Books) at 209.

Death is fearful, yet we carry our death within our lives.  Is the essential fear we are talking about in the PAD regime really a fear of loss of control, over our autonomy and the descent into helplessness?  I think in this respect it is a fear of life, life’s uncertain course that leads to our inevitable demise.  This fear of life is the adjunct of the fear of death.   Many of us maintain a certainty that our life is predictable and we can control things that happen to us, if we maintain that fantasy then most certainly are disease, disability and death an affront to our choice, an assault to our personal belief system and no longer simply part of life.  What if we were to do as Lau Tzu suggests – “take care with the end as you do with the beginning.”

I will close this first portion of the discussion of this proposed legislation with an insight from David Wendell Moller’s book “Life’s End: Technocratic Dying in an Age of Spiritual Yearning,) (2000:Baywood) at 159:

 . . . the sequestering of dying patients protects ordinary people from the terrorizing issue of death. . . . [the hospital’s] technological coordination of dying serves to submerge, deny and organize the dying process into professionally restricted categories which restrain the expression of personal pinings and fears for both providers and patients.”

It seems to me that the PAD bill serves to further the marginalization of the dying.  More about that in my next post.

©Barbara Cashman  2015   www.DenverElderLaw.org