Why L.G.B.T.Q. Adults Are More Vulnerable to Heart Disease

Experts say that a leading cause of death often goes overlooked.

By Dani Blum

As lots of U.S. residents have been celebrating Pride this month, many in the medical community have highlighted the devastating disparities in health outcomes for L.G.B.T.Q. adults — disproportionate cases of monkeypox in men who have sex with men, high reported rates of alcohol abuse, obstacles to accessing screening and treatments for cancer.

But according to some health experts, one of the most critical health inequities among L.G.B.T.Q. adults often goes overlooked.

A mounting body of research shows that L.G.B.T.Q. adults are more likely to have worse heart health than their heterosexual peers. Lesbian, gay and bisexual adults were 36 percent less likely than heterosexual adults to have ideal cardiovascular health, the American Heart Association concluded in 2018, based on surveys of risk factors like smoking and blood glucose levels. In 2021, the organization released a statement on the high rates of heart disease among transgender and gender diverse individuals, linking these elevated rates in part with the stress that comes from discrimination and transphobia.

The data supports what clinicians, and those who research L.G.B.T.Q. health, have observed for decades — that the community faces particular, pervasive obstacles that take a toll on the brain and body.

Cardiovascular disease is the leading cause of death in the United States. The Centers for Disease Control and Prevention estimates that 80 percent of premature heart disease and strokes are preventable. But there are disparities in where this burden falls among the general population. We spoke to doctors and health researchers about why these inequities persist, and what steps L.G.B.T.Q. adults can take to bolster their heart health.

The strain of stress

Experts said L.G.B.T.Q. adults face unique stressors — stigma, discrimination, the fear of violence — which can both indirectly and directly lead to disease.

Stress directly impacts certain hormones that regulate your blood pressure and heart rate, said Billy Caceres, an assistant professor at the School of Nursing and the Center for Sexual and Gender Minority Health Research at Columbia University.

Hypervigilance — the sense of always being on edge, constantly scanning for the next threat — causes cortisol levels to surge, which can lead to long-term cardiovascular issues, said Dr. Carl Streed, an assistant professor at Boston University School of Medicine.

Plus, stress can lead to chronic inflammation, said Dr. Erin Michos, associate director of preventive cardiology at Johns Hopkins University School of Medicine, and it can raise your blood pressure and heart rate.

Researchers sometimes refer to the allostatic load, the cumulative toll that chronic stress takes on the brain and body, said Scott Bertani, the director of advocacy at HealthHIV, a nonprofit focused on advancing prevention and care for people at risk for H.I.V. “It only stands to reason that our bodies respond to these really complex and challenging life events and demands,” he said. For instance, he added, the act of coming out, and in some cases, coming out repeatedly, often comes with severe stress.

To cope with the constant threat of discrimination or harassment, many in the L.G.B.T.Q. community self-medicate with drugs like tobacco and alcohol, said Dr. Streed, who is also a researcher at the Center for Transgender Medicine and Surgery at Boston Medical Center. These industries have targeted the L.G.B.T.Q. community through advertising, he said, especially during Pride month. The Centers for Disease Control and Prevention reports that around 25 percent of lesbian, gay or bisexual adults used a commercial tobacco product in 2020, compared with 18.8 percent of heterosexual adults, a disparity the agency partially attributes to the tobacco industry’s long history of aggressive marketing campaigns.

Research has also identified a link between sleep and heart health, Dr. Caceres said. Mounting evidence shows that L.G.B.T.Q. adults experience more sleep issues and interruptions than the general population, which may also be tied to chronic stress.

Obstacles to seeking care

A 2017 survey of nearly 500 L.G.B.T.Q. adults by researchers at Harvard T.H. Chan School of Public Health and the Robert Wood Johnson Foundation found that more than one in six reported avoiding health care because they worried about discrimination. That hesitancy means that L.G.B.T.Q. adults are less likely to access potentially lifesaving preventive health care, said Dr. Michos. All adults should be screened at least once a year for cardiovascular risk factors, which is typically part of an annual physical, she said.

Finding medical providers that you feel comfortable and safe around can be key in preventing heart disease, experts said. Dr. Streed recommends that L.G.B.T.Q. adults seek out supportive medical practitioners. The Gay and Lesbian Medical Association offers a directory on its website that allows patients to find health professionals. The Human Rights Campaign creates an annual Healthcare Equality Index — a list of health care facilities that say they are inclusive of L.G.B.T.Q. patients.

What L.G.B.T.Q. adults should know about improving heart health

While gender-affirming hormones have been shown to positively impact mental health, Dr. Michos said, there is some evidence that high amounts of testosterone and estrogen can have cardiovascular risks. People who are taking these hormones should consult their doctors about how to maintain their heart health.

The American Heart Association recommends seven steps for optimal heart health: managing blood pressure, keeping cholesterol levels low, reducing blood sugar, exercising daily, eating a nutritious diet, maintaining a healthy body weight and not smoking. Dr. Michos also recommended minimizing consumption of processed foods, sugar-sweetened beverages and highly refined carbs, instead opting for whole grains, lean proteins, and plenty of fruits and vegetables. Adults should also aim for at least 30 minutes of moderate-intensity exercise each day, like brisk walking, jogging or cycling.

These are critical facets of preventing heart disease, she added, “but we can’t just preach ‘You need to live a healthy lifestyle’ if individuals are under significant psychological distress and discrimination.”

Social support can help buffer against the physical and psychological strain of stress, she said, and seeking out community can be particularly crucial for L.G.B.T.Q. health outcomes. Several organizations can help L.G.B.T.Q. people connect with one another: SAGE, a nonprofit focused on aiding older adults, matches volunteers with L.G.B.T.Q. people over the age of 55 for weekly phone calls. The Trevor Project, which provides crisis intervention and suicide prevention services to L.G.B.T.Q. young people, also offers an online community for those between 13 and 24. The Bisexual Resource Center, a nonprofit focused on bisexual issues, maintains a list of online and in-person support groups for bisexual people.

“L.G.B.T. health isn’t just about H.I.V. prevention,” Dr. Caceres said. “A lot of the time, it ends up being focused on that. Sexual health is not the only dimension of health that we as queer people should be thinking of.”

Complete Article HERE!

Death Doesn’t Discriminate, So Why Are We Afraid of Living?

By Dielle Ochotorena

If you knew what day you would die, what would you do? Would you be more ambitious and try to do everything you didn’t get to do or wanted to do? Would we fall apart and die at the hands of ourselves? Would we say goodbye to our loved ones? Would you welcome death with open arms? Would you hold a funeral for yourself? Would you try to cheat death? Would you keep living life the same way until you died? Would you try to leave a legacy? To build something that will outlive you? But most importantly, would you live?

Yes, I know, we’re young, scrappy, and hungry and not throwing away our shots (I couldn’t resist these Hamilton references), so why would we even be thinking about death and legacies at this age, doing so you’d have to be obsessed with death or a goth. But here I am, an otherwise healthy twenty-one-year-old college senior talking about death and dying when most people would think, “well she hasn’t really lived yet so what does she know”. And they would be right, I know nothing about death and while I’ve had people in my life die, I don’t know really know how it feels to die. Because you don’t feel death and you don’t feel like you’re dying until you’re actually dying; you feel grief, sorrow, and despair and while that’s painful, that’s not dying. But it’s my job to provide a perspective into topics we don’t like to talk about and most often don’t even think about.

Our mortality is much closer than we think it would be, we can die tomorrow and never live to old age like the generations before us. Many things can kill us today and in the next decades. To put things into perspective, according to scientists that by the year 2050, human civilization would collapse if nothing is done about battling climate change. With rising world temperatures from carbon emissions and greenhouse gases, globally we would have more frequent and intense heatwaves, crop failures, more severe extreme weather storms like hurricanes, and massive plant and animal extinction with habitat destruction and pollution caused by rising sea levels and human destruction.

In the United States, unlike the rest of the world, life expectancy rates have dropped steadily since 2015 due to drug deaths and an increase in suicide rates. While yes, the Baby Boomer generation is getting older and they account for a significant number of deaths, it’s an increase in deaths by individuals between the ages of 24 to 44 that are the most pressing and made the most impact on the calculations of life expectancy. The 10 leading causes of death: heart disease, cancer, unintentional injuries, chronic lower respiratory diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide. Suicide and unintentional injuries have seen an increase in numbers, both are highly preventable deaths. The leading causes of death for those aged 1-24 years are mainly caused by external causes, not chronic health conditions. Unintentional injuries accounted for 38% of all deaths, followed by 13% for homicides, and 12% for suicides.

I hate to be a downer by talking about death and the real plausible reasons we how might die. But it’s eye-opening, isn’t it? Our lifelong struggle to learn how to really live is being held hostage by two notions: our mortality and the sheer dread and denial we have towards it. Dying is easy, living is harder. I can’t offer you a plan on how to live but I can plant that seed in your mind of why you need to live. While yes you could die of the aforementioned things above and I’m sorry to scare you into thinking you might die sooner rather than later, but that’s my whole point: to scare you into living.

I think it’s safe to say that we’re all just temporary fixtures in the universe, here for a set time but not made for forever. I want us all to live, to stop worrying that it will be the end of the world if you fail that exam, the dread of not getting into that graduate school program, the anxiety of possibly not having a job after college, to stop playing it safe and go out and experience life because you don’t know when it ends or when your friends will no longer be by your side. Stop thinking about the future in terms of the goals you’ve set for yourself because that’s not what most people will remember of you and what you’ll remember of your life. You’re running out of time so stop waiting for it, for that future you aren’t even sure you’ll have.

Think about the fun stories you’ll never get to tell because you weren’t brave enough to go experience it, the many versions of yourself that you won’t become because you’ve played it safe with life, the many places you’ll never go to, and the people you’ll never meet who will make an impact in your life and maybe even fall in love with. So, go. Go take that class you want to take, apply for that job you’re not qualified for, take that spontaneous trip to New Orleans, get that tattoo, try those foods you were too scared to try, make some regrets and learn from them, and meet new people who will change your life forever. Go make some memories.

Complete Article HERE!

Causes of Mortality

Our Perceptions vs. Reality

by Jennifer Thomas and Juli Fraga

Understanding health risks can help us feel empowered.

Death, as the old adage goes, is one of only two certainties in life (the second being taxes).

But when it comes to what actually kills us, are we really correct in our assumptions? As it turns out, no.

Recent data gathered by UCSD students that looks at the biggest causes of mortality shows we might be worrying about the wrong things — partially as a result of what we see covered the most in the media.

This particular data set looks at 10 of the leading causes of death, including three causes of mortality that receive substantial media attention.

The conclusion?

Many of us have false expectations about death. There’s a sizeable discrepancy between how people think we die and how we actually die.

So how does this false vision of death impact us? How far from reality are we? What are the real numbers behind the causes of death — and what do they actually tell us?

The answers and the data may well lead you to a proactive (and preventive) healthcare approach.

Media coverage doesn’t offer a clear indication of what’s actually killing us

The data shows that what the media is covering in terms of what kills us doesn’t always accurately represent the truth. And this can do more harm than good.

When people hear these things, they take them to heart.

The result: Anxiety and fear can spike, resulting in avoidance behaviors that impact a person’s well-being. Even worse, people living with mental health conditions, such as depression, anxiety, and post-traumatic stress disorder may be triggered by media reports, which can worsen their symptoms.

When inaccurate news becomes widespread, it leads people to believe danger exists where it may not. Like a game of telephone, this false information can get twisted and create a larger problem that doesn’t truly exist.

There’s also the issue of people’s expectations about death that are affected by the media focusing more on the things less likely to kill us.

Why it’s important to understand what truly has the most potential to kill you

Thinking about our own end of life — or death — at all can be uncomfortable. But it can also be extremely beneficial.

Dr. Jessica Zitter, an ICU and palliative care physician explains it this way: “Understanding the typical trajectories that are usually seen as people approach the end of life can be very helpful because if people know what final exit paths tend to look like, they are more likely to be prepared for their own as it approaches.”

Zitter goes on to say: “The media tends to ignore death from disease, while death from suicide, terrorism, and accidents are atypical in reality [based on the statistics] but sensationalized in the media. When death is treated in an unrealistic way, we rob people of the opportunity to attend to disease and make plans for the death that they would want to have.”

“You cannot have a good death if you don’t believe you are going to die. When the media misdirects our attention from death by disease to death from sensationalized causes, it implies that death can be avoided if these extreme circumstances can be avoided,” she says.

You can learn more about Dr. Zitter’s work in her book, Extreme Measures.

So what does that data say?

While heart disease and cancer together make up more than halfTrusted Source of all causes of death in the United States, these two health conditions are less than a quarter of what’s covered by the media.

So while these two conditions make up a large portion of what kills us, it’s not necessarily being covered in the news.

On the other side of the spectrum, terrorism accounts for less than 0.1 percent of deaths, despite the fact that it makes up 31 percent of news coverage. In fact, it’s overrepresented by a whopping 3,900 times.

Meanwhile, though terrorism, cancer, and homicides are the causes of death that are most mentioned in newspapers, only one is actually in the top three causes of mortality.

Furthermore, homicide is more than 30 times overrepresented in the media, but only accounts for 1 percent of total deaths.

Our concerns drastically differ from the facts

As it turns out, the causes we worry about killing us — demonstrated by what we Google the most — aren’t often in line with what actually ails Americans.

What’s more, Googling symptoms or potential things that can kill us without also discussing these things with a doctor can cause anxiety to arise. This can, in turn, set off a stream of unwarranted ‘what if’s’ such as “What if such and such happens?” “What if I’m not prepared?” or “What if I die and leave my family behind?”

And these unsettling thoughts can catapult your nervous system into overdrive, igniting the body’s stress response, also known as “fight or flight.” When the body enters this state, the heart beats faster, breathing becomes more shallow, and the stomach churns.

Not only is this physically uncomfortable, but it can also impact your physical health by raising blood pressure, heart rate, and lowering immune system functioning.

Now, back to the data…

It would seem that while we should be focusing on heart disease — which is responsible for 31 percent of deaths — it’s only 3 percent of what people search for on Google.

Conversely, searches for cancer are disproportionate to the actual likelihood of getting the disease. While cancer does make up a large portion of deaths — 28 percent — it accounts for 38 percent of what’s searched on Google.

Diabetes, too, shows up in Google results (10 percent) far more than it causes death (3 percent of total deaths).

Meanwhile, suicide has several times more relative share in the public’s eyes compared to the actual death rate. While only 2 percent of deaths in the United States are by suicide, it makes up 10 percent of what the media focuses on and 12 percent of what people search for on Google.

But there’s good news — we’re not always off the mark

Despite the obvious disparities about what causes mortality versus reported causes of death, some of our perceptions actually are correct.

Stroke, for example, makes up 5 percent of deaths and is in about 6 percent of news coverage and Google searches. Pneumonia and influenza, too, are consistent across all three charts, accounting for 3 percent of deaths and 4 percent of both media focus and Google searches.

While it might not seem like a big deal to have a firm grasp on the realities of what causes us to die, there are definite psychological and physical benefits that come out of this awareness.

Understanding health risks and safety concerns can help us better prepare for unforeseen outcomes, which can feel empowering — like taking preventive measures for heart disease.

When you know about risk factors, you can also seek comfort from healthcare professionals who can answer questions and offer reassurance. For example, someone worried about cancer may receive additional health screens from their physician, which can help them take charge of their well-being.

So next time you find yourself worrying about a news report you’ve just read or a disease you only just learned about but are Googling at 3 in the morning, take a step back and consider whether you really need to be worrying.

A better understanding of death allows us to embrace a better understanding of our life and health, so we can own it — every step of the way.

Complete Article HERE!

War on words…

Cancer is a disease, not a battle

Emeritus professor Alan Bleakley and cancer patient Jacinta Elliott on the use of military metaphors, and Adrienne Betteley of Macmillan Cancer Support on end-of-life care

It is heartening to see a front-page article on the burden that the use of cancer war metaphors may place on patients (Cancer war metaphors may harm recovery, 10 August), but we should also note that such metaphors continue to place a burden on doctors and nurses, framing contemporary healthcare – dominated by medicine – as heroic, rather than pacific.

Further, it is simply wrong for the researchers that you quote to say of the relationship between martial metaphors and their impact on patients that “nobody has actually studied it”. Particularly since Sam Vaisrub’s 1977 book Medicine’s Metaphors and Susan Sontag’s 1978 polemic Illness as Metaphor, studies have isolated differing effects of a wide-ranging typology of violence metaphors on patients by age, sex and demographics. Professor Elena Semino and colleagues at the University of Lancaster have been at the forefront of such research in the UK for many years. Global research in the field is summarised in my 2017 book Thinking With Metaphors in Medicine.

To understand why war metaphors have such traction in medicine, we have to take a historical view. In 1627 the poet John Donne described how he thought he was dying from a fever that “blows up the heart”, that is a “cannon shot”. In the mid-17th century, the most famous physician in England, Thomas Sydenham, said that “disease has to be fought against, and the battle is not a battle for the sluggard”. Two centuries later, Louis Pasteur described illness as invading armies laying siege to the body that becomes a battlefield.

The phrase “war against cancer” was first used in the British Medical Journal in 1904. In 1971, Richard Nixon famously declared a “war on cancer”. No wonder that today’s patients are so readily stigmatised in the wake of centuries of martial insults. Isn’t a “hospital” supposed to be a place for “hospitality”?
Alan Bleakley
Emeritus professor of medical education and medical humanities, Plymouth University

Cancers are as variable as the people who develop them, so I heartily endorse comments made by Martin Ledwick, Cancer Research UK’s head information nurse, about everybody needing to find their own way of talking about it.

Battling metaphors hold an implicit suggestion that patients who succumb quickly have in some way failed to fight hard enough or have somehow “given in”, and that patients like myself who survive beyond their expected prognosis are in some way “tougher”.

Your report on recent research indicates that people can be put off seeking early treatment if the type of metaphors being used make it all sound too difficult and daunting.

This is very worrying as all the research shows that the earlier symptoms are detected, the better the chance of successful treatments and quality of life post-diagnosis.

There have been major advances in cancer treatments over the last few years. Instead of using off-putting language that deters people from getting symptoms investigated, we should broadcast news of steady progress in quicker identification and consequent longer life expectancy. So no “cure” as yet, but better options for living with cancer for as long as medically sustainable.
Jacinta Elliott

The ONS mortality report shows that dementia continues to be the leading single cause of death (Dementia is ‘biggest killer in England and Wales’, 7 August). But, if all cancers were grouped together then the disease would top the table.

Unfortunately, despite cancer accounting for over 145,000 deaths in 2018 (27% of the total), we know that thousands with the disease do not spend their final days as they would wish. Some are in hospital when they would rather be at home; others face insufficient pain relief, or are unaware of the choices available to them at the end of their lives.

This autumn, as NHS bodies draw up their plans for the next five years, it is critical that they set out how people at the end of life can get the truly personalised care they need.

Our hard-working NHS professionals do everything in their power to provide care and comfort at this crucial time, but there simply aren’t the numbers of staff with the right skills to have the important and compassionate conversations needed. It is vital that staff are provided with support and training so that they can prompt open discussions as early as possible and ensure people’s wishes are taken into account.

The only certainty in life is death, and we need to make sure that everyone has choice and dignity when it comes.
Adrienne Betteley
End-of-life care specialist adviser, Macmillan Cancer Support

Complete Article HERE!

5 strange causes of death in the medieval period

Tasked today with confirming and certifying deaths resulting from unnatural or unknown causes, coroners were officially introduced in England in 1194, primarily for the purpose of collecting taxes. But their early records of deaths that occurred in unusual or suspicious circumstances offer an incredible insight into daily life, attitudes and living conditions in the Middle Ages that we would not otherwise be privy to…

Here, Janine Bryant from the University of Birmingham, who has researched medieval coroners’ rolls of three English counties – Warwickshire, London and Bedfordshire – reveals some of the most intriguing causes of death… 

1 Animals

Animals were responsible for numerous deaths in the medieval period.At Sherborne, Warwickshire in October 1394, a pig belonging to William Waller bit Robert Baron on the left elbow, causing his immediate death. Similarly, in London in May 1322 a sow wandered into a shop and mortally bit the head of one-month-old Johanna, daughter of Bernard de Irlaunde, who had been left alone in her cradle “at length”.

Cows appear to have been somewhat difficult to manage in the Middle Ages, and caused several deaths, including that of Henry Fremon at Amington, Warwickshire in July 1365. He was leading a calf next to water when it tossed him in and he drowned.

2 Drowning

People of all ages fell into wells, pits, ditches and rivers, and the coroners’ rolls of Warwickshire, London and Bedfordshire all record that drowning was responsible for the largest percentage of accidental deaths.

In August 1389 at Coventry, Johanna, daughter of John Appulton, was drawing water when she fell into the well. The incident was witnessed by a servant who ran to her aid, but while helping her fell in also. This was overheard by a third person who also went to their aid – he too fell in, and all three subsequently drowned.

3 Violence

While there are some regional and gender differences, approximately half of the entries in the medieval coroners’ rolls record violent deaths that occurred both within and outside of the home.

One domestic incident occurred at Houghton Regis, Bedfordshire in August 1276, when John Clarice was lying in bed with his wife, Joan, at the hour of midnight. “Madness took possession of him, and Joan, thinking he was seized by death, took a small scythe and cut his throat. She also took a bill-hook and struck him on the right side of the head so that his brain flowed forth and he immediately died”. Joan fled, seeking sanctuary in the local church, and later abjured the realm [swore an oath to leave the country forever].

Others deaths occurred in more mysterious circumstances: in Alvecote, Warwickshire in April 1366, Matilda, the daughter of John de Sheyle, was crossing some woods when she discovered an unknown teenage boy who had been feloniously killed and was found to have multiple wounds.

The rolls record that deaths frequently arose from disputes, and thus many seem to have been unpremeditated acts. The weapon often appeared to have been whatever was at hand, such as the case of Thomas de Routhe who died at Coventry in May 1355 after he was hit on the head with a stone.

4 Falls

There are many accounts of people who fell to their death, and they did so in a variety of ways: at Coventry in January 1389, Agnes Scryvein stood on a stool to cut down a wall candle. She fell off, landed on the stand for a yarn-winder, and ailed for two hours before eventually dying of her injuries.

At Aston, Warwickshire in October 1387, Richard Dousyng fell when a branch of the tree he had climbed broke. He landed on the ground, breaking his back, and died shortly after.

A London case occurred in January 1325 at around midnight when “John Toly rose naked from his bed and stood at a window 30 feet high to relieve himself towards the High Street. He accidentally fell headlong to the pavement, crushing his neck and other members, and thereupon died about cock-crow”.

5 Fun

The coroners’ rolls show that the Middle Ages weren’t all doom and gloom, and that people did actually have fun – although it occasionally ended in disaster.

At Elstow, Bedfordshire in May 1276, Osbert le Wuayl, “who was drunk and disgustingly over-fed” was returning home. “When he arrived at his house he had the falling sickness, fell upon a stone on the right side of his head, breaking the whole of his head and died by misadventure”. He was discovered the following morning when Agnes Ade of Elstow opened his door.

In Bramcote, Warwickshire in August 1366, John Beauchamp and John Cook were wrestling “without any malice or considered ill-will”. In the course of their game John Cook was tossed to the ground and died the following day from the injuries he sustained.

Complete Article HERE!

Where you live may determine how you die, study suggests

By JoNel Aleccia

[A]mericans who want to ensure they have a say in how they die should examine the lessons of Oregon, a new analysis suggests.

Seriously ill people in that state are more likely to have their end-of-life wishes honored — including fewer intensive-care hospitalizations and more home hospice enrollments — than those living in neighboring Washington state or the rest of the country.

In 2013, nearly two-thirds of Oregonians who died did so at home, compared with fewer than 40 percent of people elsewhere in the US, according to the report published Wednesday in the New England Journal of Medicine. Previous research had shown that more than 85 percent of Americans say they’d prefer to die at home.

“Obviously, if you’ve spent decades trying to improve your end-of-life care, it’s pretty rewarding to see that something changes,” said Dr. Susan Tolle, director of the Center for Ethics in Health Care at the Oregon Health and Science University in Portland, who co-led the study.

The review analyzed Medicare fee-for-service claims data from 2000, 2005, and 2013, and it compared end-of-life care in Oregon and Washington — a nearby state with similar demographics and attitudes toward end-of-life care — with the rest of the US, excluding those two states.

It found that in 2013, ICU use in the last 30 days of life was about 18 percent in Oregon, compared with 23 percent in Washington and 28.5 percent in the rest of the US. Nearly three-quarters of patients in Oregon hospitalized in the last month of life were discharged to home, compared with slightly fewer than two-thirds in Washington state and a little more than half — 54.2 percent — in the rest of the US.

More than 40 percent of patients in Oregon were enrolled in home hospice in 2013, compared with about 30 percent in Washington and fewer than 20 percent in the rest of the US, the analysis found.

Oregon, which enacted the nation’s first death-with-dignity law and led the way on implementing portable medical orders for treatment at the end of life, may be reaping the results of those and other efforts, said Tolle’s coauthor, Dr. Joan Teno, a professor of medicine, gerontology, and geriatrics at the University of Washington in Seattle.

“When you look at the patterns, it’s very different than the rest of the United States,” she said. “It’s even different than a borderline state.”

Pat Duty, 64, who ran a Portland floor-covering business with her husband, Jimmy, for years, said Oregon’s palliative care culture helped guide treatment decisions after his 2013 diagnosis of lung cancer and dementia. Jimmy Duty wanted limited medical interventions; he had a do-not-resuscitate order, plus a request to avoid the ICU.

“He was very clear that quality of life was his first choice,” Pat Duty recalled. “We knew we needed to discuss these things while he could make decisions for himself. We wanted to give him the dignity and grace he deserved for his final couple of years.” He died in October 2015 at age 74.

Creating such a culture is much harder than it looks, Tolle and Teno argued. Oregon has successfully integrated awareness of end-of-life care at all levels, from state government and emergency care to individual decisions made by patients and their doctors.

“If patients’ goals are not linked to actionable care plans that are supported by local health care systems and state regulations, many patients who wish to remain at home will die intubated for all the reasons the current system fails them,” they wrote.

Across the US, there’s been a push to promote ways to indicate end-of-life treatment preferences, including advance directives, which provide guidance for future care, and Physician Orders for Life-Sustaining Treatment, or POLST, portable medical orders authorizing current care. Twenty-two states now have POLST programs and others are working on or considering them, said Tolle, who co-led the creation of POLST in the early 1990s.

But the researchers warned that, while POLST efforts are important, simply filling out the forms is not enough.

“We were highlighting that there’s no simple answer,” Tolle said. “You can’t just do one thing and think that you will change the culture of end-of-life care. It is a whole lot of work.”

Dr. Scott Halpern, a medical ethics and health policy expert at the Perelman School of Medicine at the University of Pennsylvania, has been a chief critic of POLST efforts, contending that there’s little evidence that the medical orders improve quality of life near death.

The new analysis by Tolle and Teno doesn’t fill the gap, he said. But he agreed with the authors’ contention that a focus on single interventions ignores the complexity of end-of-life decisions.

“Good end-of-life care involves physicians eliciting patients’ values, hopes and fears and making treatment decisions that align,” Halpern said.

The new analysis, which was funded by a grant from the Robert Wood Johnson Foundation, underscores that families and patients outside of Oregon must be vigilant to ensure they receive the care they want, Tolle said.

“The level of care you receive near the end of life depends more on the state you live in and the systems they have in place than your actual wishes,” she said.

Complete Article HERE!

New research identifies a ‘sea of despair’ among white, working-class Americans

Princeton economists Angus Deaton and Anne Case continue to report on sickness and early death among white, middle-aged, working-class Americans.

Sickness and early death in the white working class could be rooted in poor job prospects for less-educated young people as they first enter the labor market, a situation that compounds over time through family dysfunction, social isolation, addiction, obesity and other pathologies, according to a study published Thursday by two prominent economists.

Anne Case and Angus Deaton garnered national headlines in 2015 when they reported that the death rate of midlife non-Hispanic white Americans had risen steadily since 1999 in contrast with the death rates of blacks, Hispanics and Europeans. Their new study extends the data by two years and shows that whatever is driving the mortality spike is not easing up.

VIDEO: Here’s what you need to know about the life expectancy drop

The two Princeton professors say the trend affects whites of both sexes and is happening nearly everywhere in the country. Education level is significant: People with a college degree report better health and happiness than those with only some college, who in turn are doing much better than those who never went.

Offering what they call a tentative but “plausible” explanation, they write that less-educated white Americans who struggle in the job market in early adulthood are likely to experience a “cumulative disadvantage” over time, with health and personal problems that often lead to drug overdoses, alcohol-related liver disease and suicide.

“Ultimately, we see our story as about the collapse of the white, high-school-educated working class after its heyday in the early 1970s, and the pathologies that accompany that decline,” they conclude.

The study comes as Congress debates how to dismantle parts of the Affordable Care Act. Case and Deaton report that poor health is becoming more common for each new generation of middle-aged, less-educated white Americans. And they are going downhill faster.

In a teleconference with reporters this week, Case said the new research found a “sea of despair” across America. A striking feature is the rise in physical pain. The pattern does not follow short-term economic cycles but reflects a long-term disintegration of job prospects.

“You used to be able to get a really good job with a high school diploma. A job with on-the-job training, a job with benefits. You could expect to move up,” she said.

The nation’s obesity epidemic may be another sign of stress and physical pain, she continued: “People may want to soothe the beast. They may do that with alcohol, they may do that with drugs, they may do that with food.”

Similarly, Deaton cited suicide as an action that could be triggered not by a single event but by a cumulative series of disappointments: “Your family life has fallen apart, you don’t know your kids anymore, all the things you expected when you started out your life just haven’t happened at all.”

The economists say that there is no obvious solution but that a starting point would be limiting the overuse of opioids, which killed more than 30,000 Americans in 2015.

The two will present their study on Friday at the Brookings Institution.

“Their paper documents some facts. What is the story behind those facts is a matter of speculation,” said Adriana Lleras-Muney, a University of California at Los Angeles economics professor, who will also speak at Brookings.

She noted that less-educated white Americans tend to be strikingly pessimistic when interviewed about their prospects.

“It’s just a background of continuous decline. You’re worse off than your parents,” Lleras-Muney said. “Whereas for Hispanics, or immigrants like myself” — she is from Colombia — “or blacks, yes, circumstances are bad, but they’ve been getting better.”

David Cutler, an economics professor at Harvard who also will be discussing the paper at Brookings, said the declining health of white, working-class Americans suggests that Republican plans to replace the Affordable Care Act are akin to bleeding a sick patient. As he put it, “Treat the fever by causing an even bigger fever.”

Whites continue to have longer life expectancy than African Americans and lower death rates, but that gap has narrowed since the late 1990s. The picture may have shifted again around the Great Recession, however: Graphs accompanying the new paper suggest that death rates for blacks with only a high school education began rising around 2010 in many age groups, as if following the trend that began about a decade earlier among whites.

White men continue to die at higher rates than white women in every age group. But because women started with lower death rates, the recent mortality increase reflects a greater change in their likelihood of dying early. The numbers reported by Case and Deaton suggest that white men today are about twice as likely as they were in 1999 to die from one of the “diseases of despair,” while women are about four times as likely.

Case and Deaton play down geography as a factor in the epidemic. Yet they note that white mortality rates fell in the biggest cities, were constant in big-city suburbs and rose in all other areas. The Washington Post’s analysis published last year highlighted the same geographical signature, with a break in death rates between the two most urban classifications (big cities and big-city suburbs) and the four less urban classifications, which The Post described as an urban-rural divide.

Last week, the Centers for Disease Control and Prevention published a report on U.S. suicides by level of urbanization between 1999 and 2015, a period in which 600,000 Americans took their own lives. The report showed rising rates in each of the six urbanization classifications but found “a geographic disparity” in which rates increased as urbanization decreased. That urban-rural divide appears to have widened, particularly in recent years, the CDC reported.

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