St. Patricks Day Fun Facts- Libby Deege

St. Patrick’s Day is observed on March 17 because that is the feast day of St. Patrick, the patron saint of Ireland. It is believed that he died on March 17 in the year 461 AD. It is also a worldwide celebration of Irish culture and history. St. Patrick’s Day is a national holiday in Ireland, and a provincial holiday in the Canadian province of Newfoundland and Labrador.

In Ireland on St. Patrick’s Day, people traditionally wear a small bunch of shamrocks on their jackets or caps. Children wear orange, white and green badges, and women and girls wear green ribbons in their hair.

Many cities have a St. Patrick’s Day parade. Dublin, the capital of Ireland, has a huge St. Patrick’s Day festival from March 15-19, that features a parade, family carnivals, treasure hunt, dance, theatre and more. In North American, parades are often held on the Sunday before March 17. Some paint the yellow street lines green for the day! In Chicago, the Chicago River is dyed green with a special dye that only lasts a few hours. There has been a St. Patrick’s Day parade in Boston, Massachusetts since 1737. Montreal is home to Canada’s longest running St. Patrick’s Day parade, which began in 1824.

34 million Americans have Irish ancestry, according to the 2003 US Census. That’s almost nine times the population of Ireland, which has 4.1 million people.

Some American towns have “Irish” names. You could visit: Mount Gay-Shamrock, West Virginia; Shamrock Lakes, Indiana; Shamrock, Oklahoma; Shamrock, Texas; Dublin, California and Dublin, Ohio.

The harp is the symbol of Ireland. The color green is also commonly associated with Ireland, also known as “the Emerald Isle.”

The Irish flag is green, white and orange. The green symbolizes the people of the south, and orange, the people of the north. White represents the peace that brings them together as a nation.

The name “lephrechaun” has several origins. It could be from the Irish Gaelic word “leipreachan,” which means “a kind of aqueous sprite.” Or, it could be from “leath bhrogan,” which means “shoemaker.”

According to the Guinness Book of World Records, the highest number of leaves found on a clover is 14!

One estimate suggests that there are about 10 000 regular three-leaf clovers for every lucky four-leaf clover.

Legend says that each leaf of the clover means something: the first is for hope, the second for faith, the third for love and the fourth for luck.

Small Scale Gardens-Libby Deege

A four foot square may still be too big for your yard if you live in a townhouse or an apartment but don’t give up. Even in a tiny space like a balcony or a patio, you can still grow your own vegetables.

The variety of vegetables that can be grown in a container is growing yearly. Some of the vegetables listed below you may have never eaten or you may have had the canned variety and not liked them. Fresh vegetables have a whole different taste than canned especially when you have grown them yourself. Keep an open mind and try a few new ones every year.

Vegetables for Containers

 Beets - I hated beets for years until a friend convinced me to try fresh ones last year. Fresh beets have a whole different taste than pickled ones. These can be grown in as little space as a cake pan and are better picked small and tender, about the size of a silver dollar.

Spinach – Fresh spinach is good both cooked and raw and it is another vegetable that can be grown in a small container. The leaves are best picked young and tender. One of the best things about spinach is that it doesn’t have to grow fruit so it doesn’t need a large container to support it. This is a cool weather plant and does not like hot summer days.

Leaf Lettuce - Like spinach, leaf lettuce can be grown in a small container and doesn’t need hot summer days to mature. Pick when leaves are young and tender. Start pots at different times so you have a continuous supply. There is also a variety of miniature head lettuce that can be container grown.

Patio Tomatoes – They are coming up with more and more types of tomatoes that are suited to container growing. Traditional tomatoes take a huge amount of dirt and grow to be 3 or 4 feet tall and wide if not supported. Patio tomatoes are more compact and were bred to retain a small size and be grown in a pot. Here is a variety of cherry tomatoes that can be grown in a container.

Radishes – Like beets, radishes don’t need a huge pot to grow and mature fairly quickly. These are fun to grow and make a great addition to any salad.

Green Peppers – These take a fairly good size pot and are definitely warm weather plants but they are not difficult to grow. They can be used in a variety of dishes and freeze well. If you are feeling a bit experimental, there is a new variety of mini peppers that you can buy. They are small and colorful.

Green Beans – While I would normally not recommend growing green beans in a container, they have come up with several varieties of dwarf green beans that are recommended and actually as you can plant 16 green bean plants in a square foot I would imagine these would do fairly well in a container.

Squash – Again, while squash is not something you would normally consider a container plant, new varieties are very compatible. This mild summer Patty Pan squash is only 2 ft high and 2 ft wide. It may be too big for an apartment but then maybe not.

Eggplant – Eggplant is a mainstay in Mediterranean cooking. It’s compact size makes it an ideal choice for container growing.

Garlic Chives – This is one of my favorites. It’s a beautiful flower and every part of the plant is edible.

Swiss Chard – This link is to a rainbow variety that will perk up any spot. Fresh Swiss Chard has a sweet buttery flavor that is delicious. The grocery store variety loses SO much of the flavor that it barely resembles the garden variety. Try it fresh and sauted in a bit of olive oil with a hint of garlic.

Herbs - You can mix and match herbs in a container. Basil, thyme, sage, tarragon, rosemary will all grow fine. My choices to put together would be basil, thyme and sage. Basil is an upright annual plant while sage is kind of sprawly. Thyme is a low grower so the three together make an interesting potted arrangement. All but basil are perennial.

Keep Your Brain Alive-Libby Deege

Switching things up can be fun and it can also be good for your brain. Here are a few suggestions to incorporate into your meal time routine!! Enjoy!

Try Musical Chairs!
Have everyone switch seats. In most families, everyone has his or her "own" seat. Switching seats changes whose "position" you occupy. who you relate to, and your view of the room! It even changes how you reach for the salt and pepper!

Plan a Democratic Meal.
Let each person in the family (even the youngest) decide one item on the menu. Peanut butter and steak may not sound appetizing, but is it not going to hurt you, and it may provide material for some bizarre associations.

Introduce Novelty.
Eat Waffles or cereal for dinner. The Norwegians eat their man meal for breakfast. You could try that too. Change the order in which you eat your food. Try starting with the dessert and ending with the chips. this may seem frivolous but your brain won't think so. it's primed to handle this unexpected strategy. Change where you eat your meal- a different room, outside, on the porch on the floor, BE creative.
Try eating your food using your "wrong" hand. Small changes like this makes even the most routine acts of eating challenging!!

Get Cooking!
Cook something from scratch. It doesn't have to be a five course gourmet meal. making a simple Italian pasta sauce give all your senses a good workout. As you chop and saute onions, herbs and spices, aromas permeate the kitchen and flood you with memories. You're engaging your tactile senses when chopping and peeling, and then in testing the consistency and texture of the sauce as it reduces. A good cook constantly tastes for flavor, adding and adjusting spices a little at a time.

Just remember changing things up and doing things a little differently is great for your brain and also your spirit. Try one tonight!!

Double Down - Libby Deege

Seniors are one of the fastest-growing groups of gamblers. Between 1974 and 1994, the percentage of seniors who “recently gambled” jumped from 20 to 50 percent. And a recent study found gambling to be the most frequently identified social activity among adults over 65, with casinos and bingo surpassing movies, lunch, shopping and golf as preferred social activities.

There are a number of reasons why seniors may be vulnerable to gambling problems. Senior citizens are often catered to by casinos, with bus transportation, free or discounted meals, special rewards and other prizes that attract older individuals. Gambling may provide a distraction to escape the loss of a spouse or a medical concern. Some may have financial problems they are seeking to overcome. The attention of casino staff may reduce feelings of loneliness. Cognitive impairment may prevent the recognition of a gambling problem.


Seniors may not understand addiction and be reluctant to seek help. Studies show that seniors are at risk for developing gambling problems. A 2006 New Jersey Study found that 23 percent of New Jersey residents over 55 had at least one symptom of a gambling problem. A 2005 Pennsylvania study found that 10 percent of those over 65 in a primary care facility were at risk for problem gambling.


Signs of seniors having a gambling problem include loss of interest and participation in normal activities with friends and families, blocks of time unaccounted for, missing possessions or assets, and changes in attitude and personality. Gambling problems may also be evidenced by neglect of personal needs (food, utilities and medical), secrecy and avoidance when discussing time and money, and depression. Seniors with a gambling problem and their loved ones need to know that help is available.


The National Council on Problem Gambling (NCPG) operates a 24-hour National Problem Gambling Helpline, a link for treatment, recovery groups and other resources for problem gamblers and their family members. Often, simply a kind and helpful listener can help a senior admit to a problem and seek help. To learn more or find help, call (800) 522-4700 or visit www.ncpgambling.org.

Bullying and Senior Adults- Libby Deege

Great Article by John McDonald

You’ve seen it on the news; you’ve heard the stories. Too many times, Senior Adults find themselves victimized by unscrupulous telemarketers, con artists, and taken advantage of by dishonest insurance agents.

Now, if that isn’t bad enough, many Senior Adults who are living in Nursing Home facilities find out that they are the subjects of bullying in these facilities as well.

Senior Adults are also the number one victim of investment scams. 1 In fact, telemarketing scams are so heavily geared towards Senior Adults, that the FBI2, the Federal Trade Commission, and the AARP have taken steps to protect Senior Adults from bullying telemarketers.

Laws have been put in place, and the creation of the National Do Not Call List has made its way nationwide to prevent telemarketers from targeting unsuspecting Senior Adults.

Senior Adults are targeted for many frauds including Medicare Fraud, Credit Card Fraud, Construction or Home Improvement Fraud, Insurance Fraud, Prescription Drug Plan Fraud, Door to Door Sales Fraud, Charitable Donations Fraud, Work at Home Fraud, Foreign Lotteries Fraud, Sweepstakes Fraud, Phishing Fraud, and Internet Auction Fraud.

There are many reasons why Senior Adults are targeted for fraud and telemarketing scams. A few of them are that many Senior Adults have established a “nest egg”, and con artists are well aware that these Seniors have money.

Many con artists are well aware that the majority of Seniors are trusting and good hearted people. They have mastered the art of smooth talking them with what appears to be genuine smiles and friendly conversation. Too often, Seniors aren’t even aware that they have been the victims of con artists until it is much too late, and the con artist have far left town.

These con artists work in many arenas to victimize Seniors. From construction, to telemarketing prize giveaways, insurance claims, and investment scams, it is imperative that Seniors learn how to say no to telemarketers, sales men, and potential con artists. They must learn to hang up the phone and close the door and protect their livelihoods.

Another sad fact that targets Senior Adults to bullying con artists is the fact that many Seniors have trouble with their memory. In fact, this is another reason that con artists choose to target Seniors. Con artists will “talk a good talk” relying on the fact that many of their Senior Adult victims will be unlikely to recall every detail that would be used against them in a court of law.
Too often, the Senior Adult is unaware that they have been the victim of a scam, fraud, or con until it is much later- usually a couple months of have passed since the initial contact with the con artist. This makes the Senior Adult a potentially poor witness and hinders the rendering of justice.

The best action any Senior Adult can take to prevent themselves from the schemes and plans of dishonest con artists is to be prepared.

A great resource for all Senior Adults is their local AARP. The AARP has spent countless hours of research, and money into finding the best methods and tools to help keep Senior Adults safe.

They have worked with many federal and state organizations and have many resources available to equip Senior Adults with knowledge that will prevent them from becoming the victims of ruthless, bullying con artists.

When it comes to Senior Adults and healthcare, no one would ever suspect that their physician might be bullying them out of Medicare dollars by billing them for services they never had.

Yet it is all too familiar and happens more often then you may believe. The number one person who can catch Medicare or Medicaid fraud is the Senior Adult himself. You can help prevent Medicare fraud by looking for multiple claims for the same service, checking to see if the service being billed was actually performed, and by seeing if you were charged a higher price for equipment that you received.

If you suspect Medicare fraud, you should first contact your physician to see if it was an honest billing mistake. If after further investigation, you still have the sense that something isn’t right, you can call the Medicare Fraud hotline at 1-800-447-8477. They will investigate the mater for you.

To reduce telemarketing scams and frauds, Senior Adults can elect to have their phone number placed upon the “No Call List”. You may access your local No Call directory by visiting the website, https://www.donotcall.gov/default.aspx. At this website, you can add your phone number to the National Do Not Call directory and receive further information regarding the No Call List.

Home Improvement fraud is another area where Senior Elders need to be careful. Due to the fact that many Seniors own homes and are home during the day they are targeted by con artists who plan to win them over with friendly smiles and small talk, only to bilk them out of thousands of dollars.
When contractors come to your door offering free estimates, you need to think twice before going into any business with these people. Though they may be legitimate, there is no way to know for sure, without checking their references, checking to make sure they have valid business licenses, and above all else, get other estimates by other known companies to affirm that what they have told you is indeed fact. Finally, never give a contractor large down payments of money before you have thoroughly checked out their credentials.

Many times, Senior Adults are advised by con artists not to include their family members in any of the details of the scams. This applies to home improvement scams, telemarketing scams, and sweepstake scams.

If you believe one of your Senior relatives may be the victims of a scam, you should get involved. Many times, if Seniors have been victimized, they may fear to tell anyone because they don’t want to appear incompetent.

Senior Adults should also take extra care in guarding their Medicare cards and Credit cards. Never give out your Medicare number to anyone asking for it for a “free” service.

You should always consult with your Medicare literature to find out what services are covered and which are not. If a service isn’t covered, and a provider asks for your number, they may be committing Medicaid fraud.

Also, you should never put your pin number on your credit card. If your card was ever stolen, someone could use your card and access an ATM machine. You must take care to keep all of your personal information safe. One way that you can keep your personal information safe is by tearing or shredding all personal and financial information before throwing it away.

Many unscrupulous con artists who are looking to steal your identity will comb through dumpsters and trash bins looking for information that contains bank account numbers, social security numbers, and other persona identifications.

When traveling or going out in public, limit the amount of credit cards and personal information related documents that you bring with you. These con artists are looking to steal purses and wallets to take as much of your personal identification as possible.

The best rule is to be wary of giving out credit card numbers and Medicaid numbers unless you verify that it is a bonifide business.

Case Scenario
Margaret Mills woke in the middle of the night with pains in her chest. She managed to call 911 before losing consciousness. She was suffering from a mild heart attack. She spent nearly three weeks in the hospital before being able to return home. When she checked her Medicaid Summary statement, she noticed several charges that she did not incur.
There were two charges for ambulatory services, when she knew she had only had one trip to the hospital in the ambulance. She also noticed several charges for home rehabilitation therapy that took place on the dates that she was still in the hospital. Margaret immediately contacted the billing department of the hospital and was told that the charge was to reimburse the physical therapy she received while in the hospital.

Margaret noticed that the charges clearly stated that they took place in her home and were for a substantial amount of money.

She decided to call the Medicare hotline, which assured her that they would investigate and told her that it sounded like a case of Medicare fraud

Senior and the Internet-Libby Deege

I found an interesting article the other day I thought I would share in regards to Older Americans and their use of the Internet by Jeremy Trogg! Have a great weekend everyone!!

Libby

Though people over 60 still lag behind their younger counterparts in Internet usage, the number of seniors online is expected to swell from 14 million in 2000 to more than 27 million in by 2003, according to Internet market research firm Jupiter Media Metrix.


The main reason seniors start using computers is because of e-mail. Next, they begin researching topics such as health, investing and entertainment. Then, they start shopping and join discussion groups.

Most Internet marketing experts agree that this usage pattern is the same as the general public's.

Older Americans also have financial clout, which should also attract marketer's attention. According to the American Banking Association, older adults own 77 percent of the country's financial assets. It is just a matter of mistaken assumption right now that seniors are not using the Internet.

It is truly amazing that corporate America has yet to wake up to the idea that seniors are online with many retirees spending hours online every day and learning to shop online as well.

The biggest mistake is that marketers fail to attract older adults to their Web sites when they use flashy and complex designs. Older eyes generally have to work harder to focus on text, but companies that are interested in attracting senior markets can easily make those modifications on their site.

Plenty of white space is critical along with keeping the text on each line relatively short. This is good marketing in general but especially important to older adults.

The National Institute on Aging and the National Library of Medicine have published a brochure on how to make Web sites senior friendly. The brochure emphasizes consistent design and clearly presented text and simple backgrounds to make reading easier for older eyes.

Another thing that can be extremely important to senior adults online is that page file size should be relatively small. Since many seniors have not yet moved to broadband services and therefore rely on dial-up modems, keeping that file size small lets the page load quicker and keeps the viewer happier longer. It is all about knowing your market.

Seniors are not adverse to learning technology. They're just unfamiliar with it, and once they have access to these new tools and the knowledge of how to use them, their lives are enriched.

What Broke My Father’s Heart by Katy Butler - Libby Deege

I was sent this article by one of our Clients Daughters...thought it was a moving piece and wanted to share.

One October afternoon three years ago while I was visiting my parents, my mother made a request I dreaded and longed to fulfill. She had just poured me a cup of Earl Grey from her Japanese iron teapot, shaped like a little pumpkin; outside, two cardinals splashed in the birdbath in the weak Connecticut sunlight. Her white hair was gathered at the nape of her neck, and her voice was low. “Please help me get Jeff’s pacemaker turned off,” she said, using my father’s first name. I nodded, and my heart knocked.

Upstairs, my 85-year-old father, Jeffrey, a retired Wesleyan University professor who suffered from dementia, lay napping in what was once their shared bedroom. Sewn into a hump of skin and muscle below his right clavicle was the pacemaker that helped his heart outlive his brain. The size of a pocket watch, it had kept his heart beating rhythmically for nearly five years. Its battery was expected to last five more.


After tea, I knew, my mother would help him from his narrow bed with its mattress encased in waterproof plastic. She would take him to the toilet, change his diaper and lead him tottering to the couch, where he would sit mutely for hours, pretending to read Joyce Carol Oates, the book falling in his lap as he stared out the window.


I don’t like describing what dementia did to my father — and indirectly to my mother — without telling you first that my parents loved each other, and I loved them. That my mother, Valerie, could stain a deck and sew an evening dress from a photo in Vogue and thought of my father as her best friend. That my father had never given up easily on anything.


Born in South Africa, he lost his left arm in World War II, but built floor-to-ceiling bookcases for our living room; earned a Ph.D. from Oxford; coached rugby; and with my two brothers as crew, sailed his beloved Rhodes 19 on Long Island Sound. When I was a child, he woke me, chortling, with his gloss on a verse from “The Rubaiyat of Omar Khayyam”: “Awake, my little one! Before life’s liquor in its cup be dry!” At bedtime he tucked me in, quoting “Hamlet” : “May flights of angels sing thee to thy rest!”


Now I would look at him and think of Anton Chekhov, who died of tuberculosis in 1904. “Whenever there is someone in a family who has long been ill, and hopelessly ill,” he wrote, “there come painful moments when all timidly, secretly, at the bottom of their hearts long for his death.” A century later, my mother and I had come to long for the machine in my father’s chest to fail.


Until 2001, my two brothers and I — all living in California — assumed that our parents would enjoy long, robust old ages capped by some brief, undefined final illness. Thanks to their own healthful habits and a panoply of medical advances — vaccines, antibiotics, airport defibrillators, 911 networks and the like — they weren’t likely to die prematurely of the pneumonias, influenzas and heart attacks that decimated previous generations. They walked every day. My mother practiced yoga. My father was writing a history of his birthplace, a small South African town.

In short, they were seemingly among the lucky ones for whom the American medical system, despite its fragmentation, inequity and waste, works quite well. Medicare and supplemental insurance paid for their specialists and their trusted Middletown internist, the lean, bespectacled Robert Fales, who, like them, was skeptical of medical overdoing. “I bonded with your parents, and you don’t bond with everybody,” he once told me. “It’s easier to understand someone if they just tell it like it is from their heart and their soul.”


They were also stoics and religious agnostics. They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.


Things took their first unexpected turn on Nov. 13, 2001, when my father — then 79, pacemakerless and seemingly healthy — collapsed on my parents’ kitchen floor in Middletown, making burbling sounds. He had suffered a stroke.


He came home six weeks later permanently incapable of completing a sentence. But as I’ve said, he didn’t give up easily, and he doggedly learned again how to fasten his belt; to peck out sentences on his computer; to walk alone, one foot dragging, to the university pool for water aerobics. He never again put on a shirt without help or looked at the book he had been writing. One day he haltingly told my mother, “I don’t know who I am anymore.”


His stroke devastated two lives. The day before, my mother was an upper-middle-class housewife who practiced calligraphy in her spare time. Afterward, she was one of tens of millions of people in America, most of them women, who help care for an older family member.


Their numbers grow each day. Thanks to advanced medical technologies, elderly people now survive repeated health crises that once killed them, and so the “oldest old” have become the nation’s most rapidly growing age group. Nearly a third of Americans over 85 have dementia (a condition whose prevalence rises in direct relationship to longevity). Half need help with at least one practical, life-sustaining activity, like getting dressed or making breakfast. Even though a capable woman was hired to give my dad showers, my 77-year-old mother found herself on duty more than 80 hours a week. Her blood pressure rose and her weight fell. On a routine visit to Dr. Fales, she burst into tears. She was put on sleeping pills and antidepressants.


My father said he came to believe that she would have been better off if he had died. “She’d have weeped the weep of a widow,” he told me in his garbled, poststroke speech, on a walk we took together in the fall of 2002. “And then she would have been all right.” It was hard to tell which of them was suffering more.


As we shuffled through the fallen leaves that day, I thought of my father’s father, Ernest Butler. He was 79 when he died in 1965, before pacemakers, implanted cardiac defibrillators, stents and replacement heart valves routinely staved off death among the very old. After completing some long-unfinished chairs, he cleaned his woodshop, had a heart attack and died two days later in a plain hospital bed. As I held my dad’s soft, mottled hand, I vainly wished him a similar merciful death.


A few days before Christmas that year, after a vigorous session of water exercises, my father developed a painful inguinal (intestinal) hernia. My mother took him to Fales, who sent them to a local surgeon, who sent them to a cardiologist for a preoperative clearance. After an electrocardiogram recorded my father’s slow heartbeat — a longstanding and symptomless condition not uncommon in the very old — the cardiologist, John Rogan, refused to clear my dad for surgery unless he received a pacemaker.


Without the device, Dr. Rogan told me later, my father could have died from cardiac arrest during surgery or perhaps within a few months. It was the second time Rogan had seen my father. The first time, about a year before, he recommended the device for the same slow heartbeat. That time, my then-competent and prestroke father expressed extreme reluctance, on the advice of Fales, who considered it overtreatment.


My father’s medical conservatism, I have since learned, is not unusual. According to an analysis by the Dartmouth Atlas medical-research group, patients are far more likely than their doctors to reject aggressive treatments when fully informed of pros, cons and alternatives — information, one study suggests, that nearly half of patients say they don’t get. And although many doctors assume that people want to extend their lives, many do not. In a 1997 study in The Journal of the American Geriatrics Society, 30 percent of seriously ill people surveyed in a hospital said they would “rather die” than live permanently in a nursing home. In a 2008 study in The Journal of the American College of Cardiology, 28 percent of patients with advanced heart failure said they would trade one day of excellent health for another two years in their current state.


When Rogan suggested the pacemaker for the second time, my father was too stroke-damaged to discuss, and perhaps even to weigh, his trade­offs. The decision fell to my mother — anxious to relieve my father’s pain, exhausted with caregiving, deferential to doctors and no expert on high-tech medicine. She said yes. One of the most important medical decisions of my father’s life was over in minutes. Dr. Fales was notified by fax.


Fales loved my parents, knew their suffering close at hand, continued to oppose a pacemaker and wasn’t alarmed by death. If he had had the chance to sit down with my parents, he could have explained that the pacemaker’s battery would last 10 years and asked whether my father wanted to live to be 89 in his nearly mute and dependent state. He could have discussed the option of using a temporary external pacemaker that, I later learned, could have seen my dad safely through surgery. But my mother never consulted Fales. And the system would have effectively penalized him if she had. Medicare would have paid him a standard office-visit rate of $54 for what would undoubtedly have been a long meeting — and nothing for phone calls to work out a plan with Rogan and the surgeon.


Medicare has made minor improvements since then, and in the House version of the health care reform bill debated last year, much better payments for such conversations were included. But after the provision was distorted as reimbursement for “death panels,” it was dropped. In my father’s case, there was only a brief informed-consent process, covering the boilerplate risks of minor surgery, handled by the general surgeon.


I believe that my father’s doctors did their best within a compartmentalized and time-pressured medical system. But in the absence of any other guiding hand, there is no doubt that economics helped shape the wider context in which doctors made decisions. Had we been at the Mayo Clinic — where doctors are salaried, medical records are electronically organized and care is coordinated by a single doctor — things might have turned out differently. But Middletown is part of the fee-for-service medical economy. Doctors peddle their wares on a piecework basis; communication among them is haphazard; thinking is often short term; nobody makes money when medical interventions are declined; and nobody is in charge except the marketplace.


And so on Jan. 2, 2003, at Middlesex Hospital, the surgeon implanted my father’s pacemaker using local anesthetic. Medicare paid him $461 and the hospital a flat fee of about $12,000, of which an estimated $7,500 went to St. Jude Medical, the maker of the device. The hernia was fixed a few days later.


It was a case study in what primary-care doctors have long bemoaned: that Medicare rewards doctors far better for doing procedures than for assessing whether they should be done at all. The incentives for overtreatment continue, said Dr. Ted Epperly, the board chairman of the American Academy of Family Physicians, because those who profit from them — specialists, hospitals, drug companies and the medical-device manufacturers — spend money lobbying Congress and the public to keep it that way.


Last year, doctors, hospitals, drug companies, medical-equipment manufacturers and other medical professionals spent $545 million on lobbying, according to the Center for Responsive Politics. This may help explain why researchers estimate that 20 to 30 percent of Medicare’s $510 billion budget goes for unnecessary tests and treatment. Why cost-containment received short shrift in health care reform. Why physicians like Fales net an average of $173,000 a year, while noninvasive cardiologists like Rogan net about $419,000.


The system rewarded nobody for saying “no” or even “wait” — not even my frugal, intelligent, Consumer-Reports-reading mother. Medicare and supplemental insurance covered almost every penny of my father’s pacemaker. My mother was given more government-mandated consumer information when she bought a new Camry a year later.


And so my father’s electronically managed heart — now requiring frequent monitoring, paid by Medicare — became part of the $24 billion worldwide cardiac-device industry and an indirect subsidizer of the fiscal health of American hospitals. The profit margins that manufacturers earn on cardiac devices is close to 30 percent. Cardiac procedures and diagnostics generate about 20 percent of hospital revenues and 30 percent of profits.


Shortly after New Year’s 2003, my mother belatedly called and told me about the operations, which went off without a hitch. She didn’t call earlier, she said, because she didn’t want to worry me. My heart sank, but I said nothing. It is one thing to silently hope that your beloved father’s heart might fail. It is another to actively abet his death.


The pacemaker bought my parents two years of limbo, two of purgatory and two of hell. At first they soldiered on, with my father no better and no worse. My mother reread Jon Kabat-Zinn’s “Full Catastrophe Living,” bought a self-help book on patience and rose each morning to meditate.


In 2005, the age-related degeneration that had slowed my father’s heart attacked his eyes, lungs, bladder and bowels. Clots as narrow as a single human hair lodged in tiny blood vessels in his brain, killing clusters of neurons by depriving them of oxygen. Long partly deaf, he began losing his sight to wet macular degeneration, requiring ocular injections that cost nearly $2,000 each. A few months later, he forgot his way home from the university pool. He grew incontinent. He was collapsing physically, like an ancient, shored-up house.


In the summer of 2006, he fell in the driveway and suffered a brain hemorrhage. Not long afterward, he spent a full weekend compulsively brushing and rebrushing his teeth. “The Jeff I married . . . is no longer the same person,” my mother wrote in the journal a social worker had suggested she keep. “My life is in ruins. This is horrible, and I have lasted for five years.” His pacemaker kept on ticking.


When bioethicists debate life-extending technologies, the effects on people like my mother rarely enter the calculus. But a 2007 Ohio State University study of the DNA of family caregivers of people with Alzheimer’s disease showed that the ends of their chromosomes, called telomeres, had degraded enough to reflect a four-to-eight-year shortening of lifespan. By that reckoning, every year that the pacemaker gave my irreparably damaged father took from my then-vigorous mother an equal year.


When my mother was upset, she meditated or cleaned house. When I was upset, I Googled. In 2006, I discovered that pacemakers could be deactivated without surgery. Nurses, doctors and even device salesmen had done so, usually at deathbeds. A white ceramic device, like a TV remote and shaped like the wands that children use to blow bubbles, could be placed around the hump on my father’s chest. Press a few buttons and the electrical pulses that ran down the leads to his heart would slow until they were no longer effective. My father’s heart, I learned, would probably not stop. It would just return to its old, slow rhythm. If he was lucky, he might suffer cardiac arrest and die within weeks, perhaps in his sleep. If he was unlucky, he might linger painfully for months while his lagging heart failed to suffuse his vital organs with sufficient oxygenated blood.


If we did nothing, his pacemaker would not stop for years. Like the tireless charmed brooms in Disney’s “Fantasia,” it would prompt my father’s heart to beat after he became too demented to speak, sit up or eat. It would keep his heart pulsing after he drew his last breath. If he was buried, it would send signals to his dead heart in the coffin. If he was cremated, it would have to be cut from his chest first, to prevent it from exploding and damaging the walls or hurting an attendant.


On the Internet, I discovered that the pacemaker — somewhat like the ventilator, defibrillator and feeding tube — was first an exotic, stopgap device, used to carry a handful of patients through a brief medical crisis. Then it morphed into a battery-powered, implantable and routine treatment. When Medicare approved the pacemaker for reimbursement in 1966, the market exploded. Today pacemakers are implanted annually in more than 400,000 Americans, about 80 percent of whom are over 65. According to calculations by the Dartmouth Atlas research group using Medicare data, nearly a fifth of new recipients who receive pacemakers annually — 76,000 — are over 80. The typical patient with a cardiac device today is an elderly person suffering from at least one other severe chronic illness.


Over the years, as technology has improved, the battery life of these devices lengthened. The list of heart conditions for which they are recommended has grown. In 1984, the treatment guidelines from the American College of Cardiology declared that pacemakers were strongly recommended as “indicated” or mildly approved as “reasonable” for 56 heart conditions and “not indicated” for 31 more. By 2008, the list for which they were strongly or mildly recommended expanded to 88, with most of the increase in the lukewarm “reasonable” category.


The research backing the expansion of diagnoses was weak. Over all, only 5 percent of the positive recommendations were supported by research from multiple double-blind randomized studies, the gold standard of evidence-based medicine. And 58 percent were based on no studies at all, only a “consensus of expert opinion.” Of the 17 cardiologists who wrote the 2008 guidelines, 11 received financing from cardiac-device makers or worked at institutions receiving it. Seven, due to the extent of their financial connections, were recused from voting on the guidelines they helped write.


This pattern — a paucity of scientific support and a plethora of industry connections — holds across almost all cardiac treatments, according to the cardiologist Pierluigi Tricoci of Duke University’s Clinical Research Institute. Last year in The Journal of the American Medical Association, Tricoci and his co-authors wrote that only 11 percent of 2,700 widely used cardiac-treatment guidelines were based on that gold standard. Most were based only on expert opinion.


Experts are as vulnerable to conflicts of interest as researchers are, the authors warned, because “expert clinicians are also those who are likely to receive honoraria, speakers bureau [fees], consulting fees or research support from industry.” They called the current cardiac-research agenda “strongly influenced by industry’s natural desire to introduce new products.”


Perhaps it’s no surprise that I also discovered others puzzling over cardiologists who recommended pacemakers for relatives with advanced dementia. “78-year-old mother-in-law has dementia; severe short-term memory issues,” read an Internet post by “soninlaw” on Elderhope.com, a caregivers’ site, in 2007. “On a routine trip to her cardiologist, doctor decides she needs a pacemaker. . . . Anyone have a similar encounter?”


By the summer of 2007, my dad had forgotten the purpose of a dinner napkin and had to be coached to remove his slippers before he tried to put on his shoes. After a lifetime of promoting my father’s health, my mother reversed course. On a routine visit, she asked Rogan to deactivate the pacemaker. “It was hard,” she later told me. “I was doing for Jeff what I would have wanted Jeff to do for me.” Rogan soon made it clear he was morally opposed. “It would have been like putting a pillow over your father’s head,” he later told me.


Not long afterward, my mother declined additional medical tests and refused to put my father on a new anti-dementia drug and a blood thinner with troublesome side effects. “I take responsibility for whatever,” she wrote in her journal that summer. “Enough of all this overkill! It’s killing me! Talk about quality of life — what about mine?”


Then came the autumn day when she asked for my help, and I said yes. I told myself that we were simply trying to undo a terrible medical mistake. I reminded myself that my dad had rejected a pacemaker when his faculties were intact. I imagined, as a bioethicist had suggested, having a 15-minute conversation with my independent, predementia father in which I saw him shaking his head in horror over any further extension of what was not a “life,” but a prolonged and attenuated dying. None of it helped. I knew that once he died, I would dream of him and miss his mute, loving smiles. I wanted to melt into the arms of the father I once had and ask him to handle this. Instead, I felt as if I were signing on as his executioner and that I had no choice.


Over the next five months, my mother and I learned many things. We were told, by the Hemlock Society’s successor, Compassion and Choices, that as my father’s medical proxy, my mother had the legal right to ask for the withdrawal of any treatment and that the pacemaker was, in theory at least, a form of medical treatment. We learned that although my father’s living will requested no life support if he were comatose or dying, it said nothing about dementia and did not define a pacemaker as life support. We learned that if we called 911, emergency medical technicians would not honor my father’s do-not-resuscitate order unless he wore a state-issued orange hospital bracelet. We also learned that no cardiology association had given its members clear guidance on when, or whether, deactivating pacemakers was ethical.


(Last month that changed. The Heart Rhythm Society and the American Heart Association issued guidelines declaring that patients or their legal surrogates have the moral and legal right to request the withdrawal of any medical treatment, including an implanted cardiac device. It said that deactivating a pacemaker was neither euthanasia nor assisted suicide, and that a doctor could not be compelled to do so in violation of his moral values. In such cases, it continued, doctors “cannot abandon the patient but should involve a colleague who is willing to carry out the procedure.” This came, of course, too late for us.)


In the spring of 2008, things got even worse. My father took to roaring like a lion at his caregivers. At home in California, I searched the Internet for a sympathetic cardiologist and a caregiver to put my Dad to bed at night. My frayed mother began to shout at him, and their nighttime scenes were heartbreaking and frightening. An Alzheimer’s Association support-group leader suggested that my brothers and I fly out together and institutionalize my father. This leader did not know my mother’s formidable will and had never heard her speak about her wedding vows or her love.


Meanwhile my father drifted into what nurses call “the dwindles”: not sick enough to qualify for hospice care, but sick enough to never get better. He fell repeatedly at night and my mother could not pick him up. Finally, he was weak enough to qualify for palliative care, and a team of nurses and social workers visited the house. His chest grew wheezy. My mother did not request antibiotics. In mid-April 2008, he was taken by ambulance to Middlesex Hospital’s hospice wing, suffering from pneumonia.


Pneumonia was once called “the old man’s friend” for its promise of an easy death. That’s not what I saw when I flew in. On morphine, unreachable, his eyes shut, my beloved father was breathing as hard and regularly as a machine.


My mother sat holding his hand, weeping and begging for forgiveness for her impatience. She sat by him in agony. She beseeched his doctors and nurses to increase his morphine dose and to turn off the pacemaker. It was a weekend, and the doctor on call at Rogan’s cardiology practice refused authorization, saying that my father “might die immediately.” And so came five days of hard labor. My mother and I stayed by him in shifts, while his breathing became increasingly ragged and his feet slowly started to turn blue. I began drafting an appeal to the hospital ethics committee. My brothers flew in.
On a Tuesday afternoon, with my mother at his side, my father stopped breathing. A hospice nurse hung a blue light on the outside of his hospital door. Inside his chest, his pacemaker was still quietly pulsing.


After his memorial service in the Wesleyan University chapel, I carried a box from the crematory into the woods of an old convent where he and I often walked. It was late April, overcast and cold. By the side of a stream, I opened the box, scooped out a handful of ashes and threw them into the swirling water. There were some curious spiraled metal wires, perhaps the leads of his pacemaker, mixed with the white dust and pieces of bone.


A year later, I took my mother to meet a heart surgeon in a windowless treatment room at Brigham and Women’s Hospital in Boston. She was 84, with two leaking heart valves. Her cardiologist had recommended open-heart surgery, and I was hoping to find a less invasive approach. When the surgeon asked us why we were there, my mother said, “To ask questions.” She was no longer a trusting and deferential patient. Like me, she no longer saw doctors — perhaps with the exception of Fales — as healers or her fiduciaries. They were now skilled technicians with their own agendas. But I couldn’t help feeling that something precious — our old faith in a doctor’s calling, perhaps, or in a healing that is more than a financial transaction or a reflexive fixing of broken parts — had been lost.


The surgeon was forthright: without open-heart surgery, there was a 50-50 chance my mother would die within two years. If she survived the operation, she would probably live to be 90. And the risks? He shrugged. Months of recovery. A 5 percent chance of stroke. Some possibility, he acknowledged at my prompting, of postoperative cognitive decline. (More than half of heart-bypass patients suffer at least a 20 percent reduction in mental function.) My mother lifted her trouser leg to reveal an anklet of orange plastic: her do-not-resuscitate bracelet. The doctor recoiled. No, he would not operate with that bracelet in place. It would not be fair to his team. She would be revived if she collapsed. “If I have a stroke,” my mother said, nearly in tears, “I want you to let me go.” What about a minor stroke, he said — a little weakness on one side?


I kept my mouth shut. I was there to get her the information she needed and to support whatever decision she made. If she emerged from surgery intellectually damaged, I would bring her to a nursing home in California and try to care for her the way she had cared for my father at such cost to her own health. The thought terrified me.


The doctor sent her up a floor for an echocardiogram. A half-hour later, my mother came back to the waiting room and put on her black coat. “No,” she said brightly, with the clarity of purpose she had shown when she asked me to have the pacemaker deactivated. “I will not do it.”


She spent the spring and summer arranging house repairs, thinning out my father’s bookcases and throwing out the files he collected so lovingly for the book he never finished writing. She told someone that she didn’t want to leave a mess for her kids. Her chest pain worsened, and her breathlessness grew severe. “I’m aching to garden,” she wrote in her journal. “But so it goes. ACCEPT ACCEPT ACCEPT.”


Last August, she had a heart attack and returned home under hospice care. One evening a month later, another heart attack. One of my brothers followed her ambulance to the hospice wing where we had sat for days by my father’s bed. The next morning, she took off her silver earrings and told the nurses she wanted to stop eating and drinking, that she wanted to die and never go home. Death came to her an hour later, while my brother was on the phone to me in California — almost as mercifully as it had come to my paternal grandfather. She was continent and lucid to her end.


A week later, at the same crematory near Long Island Sound, my brothers and I watched through a plate-glass window as a cardboard box containing her body, dressed in a scarlet silk ao dai she had sewn herself, slid into the flames. The next day, the undertaker delivered a plastic box to the house where, for 45 of their 61 years together, my parents had loved and looked after each other, humanly and imperfectly. There were no bits of metal mixed with the fine white powder and the small pieces of her bones.




Katy Butler lives in Mill Valley, Calif., and teaches memoir writing at the Esalen Institute in Big Sur.