Older Homeless People Are At Great Risk of Dying

Research Describes a “Health Shock” from Losing Housing Later in Life

By Laura Kurtzman

A quarter of the participants in a long-term study of older people experiencing homelessness in Oakland died within a few years of being enrolled, UC San Francisco researchers found.

The study, funded by the National Institute on Aging, recruited people who were 50 and older and homeless, and followed them for a median of 4.5 years. By interviewing people every six months about their health and housing status, researchers were able to examine how things like regaining housing, using drugs, and having various chronic conditions, such as diabetes, affected their risk of dying.

They found that people who first became homeless at age 50 or later were about 60 percent more likely to die than those who had become homeless earlier in life. But homelessness was a risk for everyone, and those who remained homeless were about 80 percent more likely to die than those who were able to return to housing.

Becoming homeless late in life is a major shock to the system.

The median age of death was 64.6 years old, and the most common causes of death for people in the study were heart disease (14.5 percent), cancer (14.5 percent), and drug overdose (12 percent).

“Becoming homeless late in life is a major shock to the system,” said Margot Kushel, MD, who directs the Benioff Housing and Homelessness Initiative and is a professor of Medicine at UCSF and senior author of the study published August 29, 2022 in JAMA Internal Medicine.

“These untimely deaths highlight the critical need to prevent older adults from becoming homeless – and of intervening and rehousing those that do, quickly,” she said.

The study is unique for its prospective design. Previous studies of mortality in homeless populations were retrospective and drew information from medical records. By contrast, the current study – Health Outcomes of People Experiencing Homelessness in Older Middle agE (HOPE HOME) – followed a group of people, whether or not they received health care.

Many study participants had serious conditions that went untreated.

“We looked at how frequently people reported diagnosis of heart disease or cancer before dying of these diseases. It was really low,” said Rebecca Brown, MD, affiliated assistant professor of medicine in the Division of Geriatrics at UCSF. “We think this represents a lack of access to care and delayed diagnosis. Often, we didn’t even know people were ill because they didn’t report it in their six-month interviews. But we found it on their death certificates.”

Researchers went to great lengths to track down what happened to the people in the study when they missed check-ins and couldn’t otherwise be accounted for, including looking at photos of unidentified deaths at the coroner’s office, reviewing California state death records to match their participants’ names and dates of birth, querying emergency contacts, searching social media, and reading online obituaries.

They found that as of Dec. 31, 2021, 117 of the 450 people had died since the study began enrolling in 2013. Nearly 40 percent (45) occurred after the pandemic started in March of 2020, but just three of those deaths were from COVID-19. Participants entered the study in two waves, with 350 enrolled in 2013-14 and another 100 enrolled in 2017-18; 101 of the deaths were from the first wave, and 16 were from the second.

Mortality rates were high compared to the general Oakland population. The risk of dying was 3 times higher for men and 5 times higher for women, compared to people of the same age and sex in Oakland. The median age for participants entering the study was 58, and 80 percent were black; 76 percent were male, and 24 percent were female.

The study also contained detailed information about people’s use of drugs and alcohol, as well as their mental health. But drug and alcohol use itself was not independently associated with death.

“The streets are just no place to live,” said Johná Wilcoxen, 72, who spent more than a decade living in his car when he lost Section 8 housing because his children moved out. Through his ordeal he continued working as a plumber, which gave him a place to go during the day and money for food. “The more people as we can get off the street, the better,” he said.

Complete Article HERE!

When and why did humans start using tombstones?


As grave markers, tombstones offer a focus for mourning and commemoration. Typically made of stone and usually engraved with the deceased’s name, date of birth and death, they also often carry inscribed tributes. They’ve been around a long time, across a wide variety of cultures.

“Numerous Neolithic stone statues called stelae, associated with Kurgan culture burials about 5,000 years old, were found in Ukraine and Moldova,” reveals Čaval. “We also have Bronze Age stone and wooden markers on mounds. The Greeks buried commoners and elites in marked graves. There’s the pre-Roman Vulci in Italy, followed by the abundant Roman tombstones, with statues, reliefs and inscriptions telling stories,” she adds.

Why deaths are written in stone

As Čaval explains, the first epitaphs as we now know them, especially the formula “Here lies…”, comes from the Greek tradition. Adopted by the Romans, thanks to the spread and influence of their empire, this became the standard in the West.

More than just words, the aesthetics of tombstones also tell us about the beliefs of their creators. “The specifics tell us something unique about the times in which they are made—about communities, their identity, values and beliefs, about both life and the afterlife,” says Čaval.

Most obviously, a tomb’s location can reflect the deceased’s personal attachment to a specific location, while craftmanship and materials can reflect social status, especially if rare. Inscriptions are indications of literacy, while decorative motifs can suggest religious affiliations.

“Even without decoration or inscription, the tombstone’s shape, position within a cemetery, type of cemetery, all help build a picture of what a society values and how individuals fit into these values,” adds Čaval.

The stećci enigma

Čaval’s expertise and interest in understanding the past through burial practices and their material culture, were sparked by the Western Balkans’ little known stećci, gigantic stone monuments found at gravesites.

Decreed a UNESCO World Heritage Site in 2016, the stećci are medieval tombstones, preserved across the landscapes of Bosnia and Herzegovina, Croatia, Montenegro and Serbia.

“Remarkably, these are not attributed to any ethnic or religious group and so have always been considered enigmatic. But their numbers, with over 70,000 preserved, alongside their monolithic character reflect their importance, many centuries ago,” says Čaval.

Some tombstones have inscriptions written in Glagolitic and Bosnian Cyrillic scripts, both extinct today. This speaks to local ethnic and religious diversity, substantiated by prehistory decorations mingling with Roman Christian or Islamic elements.

“We’re using modern digital techniques like to explore this phenomenon and I’m proud to help publicize them,” reflects Čaval.

Are the cracks showing in tombstones?

The simplest reason for tombstones’ success is that they are fit for purpose. Suitable has been relatively easy to find and transport to gravesites. It can be decorated. Stone is hard-wearing, enduring and the passage of time—ensuring a lasting tribute. Which also explains why other grave markers, whatever they might have been, are lost to time.

With the rise of humanist funerals and with cemeteries facing overcrowding, accompanied with increasing sustainability concerns—are tombstones falling out of favor? “There is definitely a trend for alternatives but I think there will always be a place for tombstones. Their reassuring solidity literally represents a life, keeping it present and so relevant,” concludes Čaval.

Complete Article HERE!

And Finally

— Matters of Life and Death review – humility lessons from Henry Marsh

‘Darkly funny and self-lacerating’: Henry Marsh at home in Oxford, June 2022.

The ever candid neurosurgeon reflects on his own mortality, as well as the failings of his profession, in this enthralling third volume of memoirs


“I am not a scientist,” says Henry Marsh on the first page of And Finally. “Most neurosurgeons are not neuroscientists – to claim that they all are would be like saying that all plumbers are metallurgists.”

Marsh, who worked as a highly regarded neurosurgeon for more than 40 years, has a penchant for truth-telling, unencumbered by faux modesty. It’s what made his previous books – Do No Harm and Admissions – interrogating a life in medicine, haunted by the “reproachful ghosts” of patients he’d failed, so refreshing and inspiring to read.

This latest autumnal instalment follows in the same vein. Philosophical and scientific conundrums about brain surgery permeate the book: to treat or not to treat patients; how honest to be in giving a prognosis; euthanasia v assisted dying. Along the way the 72-year-old author wrestles with the dilemma of becoming a patient himself.

The memoir’s subtitle and celestial cover design allude to the 1946 Powell and Pressburger film, A Matter of Life and Death. It’s befitting as Marsh reflects on his own mortality after a diagnosis of advanced prostate cancer. He is phlegmatic about his prospects. Sometimes, though, he confesses to paralysing anxiety – a result of his approach towards serious problems that his wife, Kate, calls “therapeutic catastrophising”.

Despite its subject this is not a maudlin book; far from it. Divided into parts like a three-act play, it is often darkly funny, especially in the first act, Denial. Here, Marsh is self-lacerating and also self-forgiving when he reminisces about his medical mistakes. On one occasion he steels himself to admit to a patient that he’d operated on the wrong side of his brain. “Well, I quite understand, Mr Marsh,” the patient answers after a long silence. “I put in fitted kitchens for a living. I once put one in back to front. It’s easily done.”

Marsh is nonetheless fierce on himself throughout the book, as critical as he is of the arrogance of his profession. Now that he’s a patient, he sees clearly how he’s been demoted to an underclass; how some doctors behave as if patients are nothing more than walking pathology; and how they continue to practise medicine under the delusion (once also held by Marsh) that illness only affects patients, not doctors.

Elsewhere, he strikes a sadder personal note, recounting the end of a decades-long friendship with a conscientious Ukrainian neurosurgeon who figured prominently in his earlier memoirs. Working with him in poorly resourced Ukrainian hospitals had left Marsh feeling heroic. But he split from his colleague after discovering he’d been hiding from him a number of cases that had gone terribly wrong, with patients seriously harmed or dying after surgery.

It’s not stated whether Marsh also feels culpable, but certainly he agonises over his professional legacy. That anxiety folds into his nervousness about the future we are bequeathing to our children and grandchildren through inaction over climate change. In one startling passage, he recalls a journey in the Indus delta where he witnessed a catastrophic spectacle: “a flotilla of plastic rubbish … it had neither beginning nor end. It floated past us in complete silence … full of ominous purpose”.

The retired neurologist, who in medical parlance has “hung up his gloves”, has composed a richly discursive book. He charts his ambivalence about undergoing radiotherapy for his cancer, and is especially passionate when advancing the case for assisted dying. He’s scornful of the “dishonest fudge” around the issue that sees doctors accepting the unofficial practice of prescribing large doses of opiate painkillers, as a form of “terminal sedation”.

During Covid, and the cult of death it seemed to spawn, Marsh was animated by the fear his time could run out before he finished making a doll’s house for his granddaughters. Its construction – a mournful metaphor for innocence that a future governed by global warming will deny his grandchildren – is also an act of defiance.

And Finally sounds increasingly ominous about his prostate cancer as the memoir works its way towards a resolution; Marsh is plain-speaking without being dispassionate, almost as if volunteering his own medical history as a case study. Indeed his book reminds me of the mantra – focused on operations – that I first heard at medical school, for doctors embarking on a career in surgery: “see one; do one; teach one”. Henry Marsh may have retired from medicine but let’s hope he keeps producing books as good as this one, which enthral as well as teach.

Complete Article HERE!

Life and death lessons from my very best friend

Luis Carrasco and his dog, Penelope, at the top of Humphreys Peak, the highest point in Arizona, on Oct. 11, 2014.


I have always been afraid of death. Not of dying, but of the pain of losing those I love.

I was so preoccupied with it as a child, that ever since I can remember, I said I wanted to be a doctor. This delighted my mom and dad to no end, especially when I said the reason was that I wanted to help people. The truth was I wanted to keep them from dying.

For 45 years, through emotional detachment and good fortune, I had mostly avoided that pain I so dreaded. Until a week ago, when my luck ran out and my wife and I said goodbye to our dog, Penelope. She was almost 15.

It’s fitting that having learned so much from her in life, that she had one last thing to teach me.

But before I talk about the end, let me tell you about the beginning. My wife and I had been living together for less than six months, having recently moved to Chattanooga, Tennessee, when she insisted that we get a dog.

Although I had a couple of pets growing up, they lived outside, and I felt little connection to them. In Mexico, having an indoor dog was unthinkable, it just wasn’t part of the culture. Penelope, as suits a proper Southern lady, would be raised differently.

Born Jan. 1, 2008, of a coonhound mother and a chocolate Lab father, she had a dozen siblings. About half of them were all white, the other all black. Six weeks after they were born, they barked and bounded in the back of a truck — a monochrome flurry of puppy energy — where Penelope and her brother’s mixed coats stood out.

My wife pointed at the pair, and I grabbed the male dog. She said she meant the female but that, “it was OK if we took that one.” As she always tells the story, with a tone that invokes the hand of providence, I apparently said, “No, no, let’s take the one you wanted.”

Thus, Penelope came into our lives, and, verily, I wanted to drown her in the bathtub.

We lived in a condo that shared walls with three other units and as she cried at night, what mattered to me most was that we were inconveniencing the neighbors. She peed inside the house, chewed anything she could get her paws on and demanded constant attention … for about a week.

Then, it felt longer, and now it feels shorter, but regardless, she very quickly settled into who she would be for the rest of her life: a sweet, relaxed dog who asked for very little and gave so much in return.

As I think about who I was then, and what I thought was important, I have a hard time understanding. I’m embarrassed at how sheltered I was and how even though I was 30 and married, I had so much growing up to do.

In those early days, Penelope’s biggest sin was forcing me out of my routine, out of my solipsistic comfort zone of not having to do anything for anyone else. Slowly, she not only made me a better person, but she opened my world in new ways.

Taking her for walks and going on hikes, her love for being out in nature was infectious. She took me from someone who thought twice about sitting on the grass for fear of an ant or two, to pushing through tick-infested bushes on the hunt for an elusive swimming hole. She really loved the water.

Being with her allowed me to get out of my head and enjoy myself. When I think of happiness, one of the images that always comes up is chasing Penelope, not a care in the world, as she ran around the hills of the Chickamauga Battlefield in Georgia. There are pictures, and they are silly.

Penelope sits by a lake inside Yellowstone National Park on June 1, 2021. (Luis Carrasco)
Penelope sits by a lake inside Yellowstone National Park on June 1, 2021.

She also helped me work on managing frustration, from her days when she was a rebellious puppy to her final months, when we dealt with the indignities that come with illness and old age. She could no longer walk by herself or properly control her bodily functions.

Penelope died on Aug. 20, and the pain of losing her has been at times overwhelming — emotionally and physically draining. There is a certain unreality to my days. Life had Penelope in it, so what is this now? My wife calls the whole thing surreal.

Yet, this is one more case of Penelope pushing me to grow up, to understand that death comes with pain, but it also comes with happiness. Even as tears still flow every time I think of her, afterward I am left feeling joy; blessed to have known her and for the time we shared.

I know someday the tears will stop, and the joy will remain.

Complete Article HERE!

Psychedelic trips and near-death experiences result in strikingly similar attitude shifts

The two experiences alter a person’s core beliefs in a comparable way and scientists want to understand why.

By Katie MacBride

In 2014, Tracy Morgan was in a car accident that nearly took his life. The former Saturday Night Live and 30 Rock cast member suffered near paralyzing injuries in the accident that killed his friend James McNair. In 2019, he told Oprah Winfrey how the crash fundamentally changed his attitude.

“The way I am with people, something’s just different. I find myself saying, ‘I love you’ 200 times a day to strangers.”

Such shifts in attitude about life and death are common among people who have had near-death experiences. Studies have found that those who describe themselves as having experienced near-death events have lower ratings in metrics assessing fear of death and higher ratings for belief in a happy afterlife.

Similar changes in attitude are often described by people who have psychedelic drug experiences. For example, a pivotal 2016 study that looked at the effect of psilocybin treatments in terminal cancer patients found that patients who took the drug had dramatic “increases in quality of life, life meaning, and optimism, and decreases in death anxiety.”

But what do near-death events and psychedelic experiences have in common? That’s what Johns Hopkins University School of Medicine researchers sought to parse. Their results, published Wednesday in the journal PLOS One, raise intriguing questions about what shifts our attitude toward life and death.

Here’s the background — Roland Griffiths is the director of the Center for Psychedelic and Consciousness Research at Johns Hopkins University School of Medicine. He was the first author on the 2016 psilocybin cancer patient study and has long been interested in attitude shifts resulting from psychedelic experiences.

What that study showed, Griffiths tells Inverse, is that “a single dose of psilocybin produced remarkable decreases in anxiety and depression that endured.”

What predicted these positive outcomes, he explains, was “a constellation of features of the experience.” These are classically defined as mystical experiences, though Griffiths cautions that some people may misunderstand what that means. “It’s not a supernatural thing; these have certain features that we can define empirically.”

Those features include “Sacredness, deeply felt peace and joy, transcendence of time and space,” and “internal unity and external unity.” The cliche but accurate way to describe that unity is feeling “one with the universe.” A psychedelic experience with those qualities is predictive of decreased anxiety and depression, as well as shifts in attitude about death and dying.

“If you look at the phenomenological features of near-death experiences, there’s something called a near-death experience questionnaire, it looks again suspiciously like the mystical experiences, there are so many features in common,” Griffiths says. “So that prompted us to wonder, ‘do we have a model [with psychedelics] that is very similar — in terms of brain mechanisms or psychological changes — to experiences that occur naturally.”

Griffiths and his colleagues decided to hone in on that question by directly comparing a group of people who claim to have had a near-death or “non-ordinary” experience that altered their attitudes about death and dying with a group who reported similar changes after taking a psychedelic drug.

What the researchers did — Researchers administered a survey to 3192 people. There were 900 in the near-death or other non-ordinary experience group; the remaining participants were sorted into groups based on the drug responsible for the experience in question: LSD, DMT, psilocybin, or ayahuasca — a psychoactive brew derived from specific shrubs that have traditionally been used in spiritual ceremonies by indigenous peoples in the Amazon basin.

Participants were given a series of questionnaires designed to parse different aspects of their experience and the enduring effects. To quantify the “cognitive, affective, paranormal, and transcendental” aspects of their experience, participants were given the Greyson Near-Death Experience Scale. These questions revolved around the thoughts, perceptions, and feelings that defined the person’s experience. The subjective aspects of the experience, as well as the attitude shifts following it, were evaluated using several other surveys.

What they found — One of the most striking findings is how similar the two groups were to each other.

“Almost 90 percent of both groups reported decreased fear of death following the experiences,” Griffiths says. “Both groups rated the experience very high for personal meaning and spiritual significance, and both groups reported persistent positive changes in personal well-being, life satisfaction, life purpose, and life meaning.”

Slight deviations occurred between the two groups; for example, those in the near-death experience group were more likely to report the experience as the single most meaningful of their life. The one exception was the ayahuasca subgroup, those participants rated the experience more closely to the near-death group: as the most meaningful of their life.

Interestingly, the psychedelic drug group rated the experience higher on the mystical and near-death experience questions than the participants in the actual near-death experience group.

Digging into the details — The reasons behind some of the slight discrepancies between the near-death and psychedelic groups were fairly obvious. For example, the near-death group was more likely to believe their life was in danger during the experience because, as Griffiths says, “they clinically were.”

Other differences, especially those among the psychedelic drug subgroups are less clear, though Griffiths offers some possible factors.

The ayahuasca subgroup being so similar to the near-death experience group on the singular meaningful experience metric may be the result of different demographics, or different contexts.

“The Ayahuasca group tended to be older, more affluent, and female,” Griffiths says. “And ayahuasca is more likely to be taken in a ceremonial setting. So there’s a set and setting difference there that’s distinct from psilocybin or LSD.”

While he can’t say for sure those account for the differences, they “may be very important to how those effects are interpreted.”

The answers likely won’t elude the researchers at the Center for Psychedelic and Consciousness Research for too long. They’re studying many different aspects of psychedelic-assisted therapy.

“We’re looking at different therapeutic indications for these drugs. We have studies on alcohol use disorder, OCD, anorexia, Alzheimer’s, Lyme disease, and PTSD,” Griffiths says. “We’re also looking at the brain mechanisms involved in psychedelic experiences. We have a whole line of investigation in healthy volunteers aimed at more fully understanding the longer term implications of some of these profound experiences.”

Complete Article HERE!

The pandemic changed what it means to have a ‘good death’


When considering what a “good death” is, most people in North America would likely say something along the lines of living to at least 75, and painlessly passing away at home in their sleep would constitute a good life and, most importantly, a good death. One of the key features of the “good death” narrative is being at home.

So, what do we mean by home and how important is the idea or feeling of “being at home” to a good death?

Home is more than just a structure. It is textures, smells, sounds and atmosphere. It is a sticky table that brings you back to your first day of school when you held your brother’s hand as you both walked to the bus or a smell that reminds you of the first time you baked cookies with your grandmother and danced around the kitchen singing along to Cher.

Home is nothing, but everything, especially at the end of life.

Death used to be treated as a public event, but as our society has become more individualistic, it has shifted to being a matter best dealt with in private by ritual specialists — like an embalmer or funeral director — and close family members.

As the home is thought of as being the most intimate private space we inhabit, it should not be surprising that most people wish to seek “home” in the dying process. To die outside of home is seen to be a failure — a bad death.

The pandemic changed the lives of many people. Isolated from friends and family, away from home, many people didn’t have access to a “good death” — especially those in care homes. So its important to reflect back on this idea of a “good death” and how we understand what home and family mean.

No longer an ‘uncomplicated’ death

Since the 1920s and ‘30s the government has increased its control over funerals and end-of-life treatments. This became an even greater concern in the 1950s and ’60s, when advancements in medical care meant that people who would have previously had an “uncomplicated” death now found themselves entangled in, and dependant on medicine.

With an aging population and medical advancements, the reality is that as people age, they are likely to find themselves being put in the role of “patient,” where their death will be medically mediated.

This means that even if they are able to be at home, their health is being medically determined, with the end result being that the amount of control they have over their own lives and final care has become complicated.

The ideal narrative of living to 75 and passing away at home quietly and painlessly while asleep is becoming increasingly difficult to realize.

A person stands behind square windows, wearing scrubs, wiping down a desk
A worker is seen cleaning surfaces inside a long term care home in Vancouver.

No longer at home

The fear of not having a “good death,” by dying at home among family members, has become a very real concern — especially during the pandemic.

Before COVID-19, people who lived in places like care homes would still be invited to gatherings or enjoy the occasional visit from a loved one. Their social death was isolating, but not devastating.

During peak restrictions, senior living and care facilities were locked down. This resulted in family members feeling helpless and those living in care facilities feeling hopeless.

The shutdowns, intended to keep them safe, caused many to long for a home that wasn’t restricted — some even opted to choose medically assisted death in the face of additional lockdowns.

An evolving ‘good death’

In the Netherlands, home is thought of as not just being a physical space, but is seen as a state of being in the family.

Isolated from their families during the pandemic, many individuals found themselves no longer being in the family. The social death they were experiencing was felt to be far more painful than any fear or concern they had about their own biological death.

As we reflect on what life means to us in this post-pandemic shuffle, we need to also contemplate what a “good death” is. For some, that may mean opting for quality of life and control over how, when, with whom and where it ends through end-of-life programs like MAID (Medical Assistance in Dying).

The pandemic will forever change how people understand what home and family means, what their role within the family and home is, and how to be in the family and in the home, in whatever form that may be, for their passing.

Complete Article HERE!

What’s the difference between a POLST form and an advance directive?

By Lyle Solomon

Important terms

Advance directive: An advance directive is a document specifying who will make medical choices on the patient’s behalf if and when they become incapable of doing so. This document is also called a “health care power of attorney.”

POLST form: A Portable Medical Orders form, or POLST, is a list of medical directives that only apply to a specific patient population and deal with a small number of crucial medical choices.

Question: What’s the difference between a POLST form and an advance directive?

Answer: An advance directive is not a replacement for a POLST form, nor are POLST forms an alternative to an advance directive. However, when appropriately used, advance directives and POLST forms are helpful as advance care planning tools for expressing patient preferences.

An advance directive specifies who will make medical choices on the patient’s behalf if and when they become incapable of doing so. This document is also called “health care power of attorney.” It also offers direction or instructions for choosing medical care, usually in cases involving end-of-life care, and is also referred to as a “living will.” An advance directive is not a medical order but a directive or an authoritative instruction from the patient.

A POLST form, in contrast, consists of a list of medical directives that only apply to a specific patient population and deal with a small number of crucial medical choices. The form is meant to be used in conjunction with advance directives because it ensures continuity of care and acts as a translational tool.

An advance directive, sometimes known as a living will or health care power of attorney, is used to specify the types of treatments a patient may desire to receive in the event of a future, unforeseen medical emergency. It also allows patients to name a surrogate, and this is something every adult should have.

The POLST form is a portable medical order for specific medical care the patient would need immediately, depending on their diagnosis, prognosis and care goals. It has different names in different states, and POLST forms are suitable for people close to the end of their lives and with a severe illness or frailty.

POLST forms are suitable for people close to the end of their lives and with a severe illness or frailty.

It’s highly recommended the patient has an advance directive in place before requesting a POLST form. If patients participate in a POLST conversation, they can probably choose a surrogate. A POLST form can only be created, modified or revoked by the surrogate the patient specified in their advance directive if they ever lose the ability to make decisions themselves.

Complete Article HERE!