One Friday morning this spring, I went on patient rounds with Sarah Creed, a nurse with the hospice service that my hospital system operates. I didn’t know much about hospice. I knew that it specialized in providing “comfort care” for the terminally ill, sometimes in special facilities, though nowadays usually at home. I knew that, in order for a patient of mine to be eligible, I had to write a note certifying that he or she had a life expectancy of less than six months. And I knew few patients who had chosen it, except maybe in their very last few days, because they had to sign a form indicating that they understood their disease was incurable and that they were giving up on medical care to stop it. The picture I had of hospice was of a morphine drip. It was not of this brown-haired and blue-eyed former I.C.U. nurse with a stethoscope, knocking on Lee Cox’s door on a quiet street in Boston’s Mattapan neighborhood.
I am not busy. I am the laziest ambitious person I know. Like most writers, I feel like a reprobate who does not deserve to live on any day that I do not write, but I also feel that four or five hours is enough to earn my stay on the planet for one more day. On the best ordinary days of my life, I write in the morning, go for a long bike ride and run errands in the afternoon, and in the evening I see friends, read or watch a movie. This, it seems to me, is a sane and pleasant pace for a day. And if you call me up and ask whether I won’t maybe blow off work and check out the new American Wing at the Met or ogle girls in Central Park or just drink chilled pink minty cocktails all day long, I will say, what time?
Immediately, I realized that I must dedicate my life to understanding the causes of the universe's beauty. Says: The first ten words of this essay will catch your readerâs attention, mainly because they create a mental image of perfect natural beauty.
The executives were reluctant. They normally lived in meetings worrying about strategy and budgets. They weren’t used to venturing into patient territory and didn’t feel that they belonged there. In some places, they encountered hostility. But their involvement proved crucial. In the first month, according to Christine Goeschel, at the time the Keystone Initiative’s director, the executives discovered that the chlorhexidine soap, shown to reduce line infections, was available in fewer than a third of the I.C.U.s. This was a problem only an executive could solve. Within weeks, every I.C.U. in Michigan had a supply of the soap. Teams also complained to the hospital officials that the checklist required that patients be fully covered with a sterile drape when lines were being put in, but full-size barrier drapes were often unavailable. So the officials made sure that the drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new central-line kit that had both the drape and chlorhexidine in it.
I was very interested in life in a foreign country
In late 2004, executives at Aetna, the insurance company, started an experiment. They knew that only a small percentage of the terminally ill ever halted efforts at curative treatment and enrolled in hospice, and that, when they did, it was usually not until the very end. So Aetna decided to let a group of policyholders with a life expectancy of less than a year receive hospice services without forgoing other treatments. A patient like Sara Monopoli could continue to try chemotherapy and radiation, and go to the hospital when she wished—but also have a hospice team at home focussing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe. A two-year study of this “concurrent care” program found that enrolled patients were much more likely to use hospice: the figure leaped from twenty-six per cent to seventy per cent. That was no surprise, since they weren’t forced to give up anything. The surprising result was that they did give up things. They visited the emergency room almost half as often as the control patients did. Their use of hospitals and I.C.U.s dropped by more than two-thirds. Over-all costs fell by almost a quarter.
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The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the country’s long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.
How to move to another country and start a new life - …
This might seem, as it did to many at the time, a waste of Goethe’s genius—like harnessing Pegasus to a cart. But Goethe, with the unerring instinct that seemed to guide him throughout his long life, had chosen the existence he needed—an existence as unlike Werther’s as possible. Instead of remaining focussed on his own passions and desires, he subdued his mind to the discipline of the objective, of work and responsibility. He turned toward objectivity in other ways as well, particularly in his study of science. Throughout his life, Goethe published scientific theories and “discoveries,” most of which were wrong and roundly ignored by the scientists of his day. But, while he failed to overthrow the Newtonian understanding of optics, Goethe found in science a necessary distraction from self.