Palliative Medicine
By Nathalia Schetino

In 1990, palliative care was defined by the World Health Organization as a form of care that targets the chronically ill, those who have progressing diseases that threaten the continuity of life. Such care was recommended for all countries as part of the comprehensive care for human beings. The palliative care specialist treats the patients but not their illnesses. How? They do so by looking at one’s needs and symptoms not only from the physical, but also from the emotional, social and spiritual point of view. The specialist also looks at the family and the caregiver during treatment and provides care after death in the period of mourning.

Palliative care began in oncology, but today it extends to the carriers of all chronic diseases. Patients with advanced diabetes, heart disease, or chronic lung disease benefit from receiving this type of care. However, even today, those with advanced stages of cancer constitute most patients requiring palliative care. The first step in palliative care treatment is to listen to the patient, to observe him or her as an individual who has a history, and to grasp a level of understanding of his or her own condition. The specialist must be attentive to all the characteristics and conditions of that patient. This was the way that palliative medicine oversaw the patient and his family in order to meet the needs of the family nucleus in a very personalized way - as part of the specific treatment.

From the physical point of view, besides pain, the most common symptoms targeted by palliative care are fatigue and shortness of breath, which are extremely distressing symptoms that can be controlled in a simple way without the need of great technological resources. Other problems that are focused on during treatment include nausea, vomiting, loss of appetite, weight loss, sores, depression, anguish, fear and loneliness. Palliative medicine advocates that one should always seek the cause of the symptom to try to minimize it. Fatigue, for example, can be determined by anemia or a metabolic disorder amenable to treatment. When one cannot fight the cause, there are psychostimulant drugs that can be used since they make people more willing, more cheerful, and more likely to improve their quality of life even if by a little.

It is important to note that most sick people realize when their life is coming to an end. The signs are very clear: one loses mobility in one day; the next day one cannot sit or turn in bed and depends on other’s help to make any movements. The feeling of fatigue becomes very acute, the appetite disappears completely, and it is no use imposing an artificial diet, because the individual no longer responds to any type of treatment. (In fact, to stop feeding at the end of life is providential because it makes the body produce some substances that relieve pain and discomfort.) In palliative medicine, much medication is used subcutaneously. As the picture progresses, some drowsiness and mental confusion may arise. At this stage, it is common for patients to see things and communicate with family members who have sometimes died. Gradually, however, they lose consciousness and sleep most of the time.

In this period, it is important to listen to what they have to say, to listen to their desires and needs, and to reassure their families. There are patients who ask to die at home next to a certain person. The best way to approach them at this stage is to assure them that his or her health specialist will not abandon them, that their family is there and that both the specialists and family want them to end their lives in peace.

References:
https://www.liebertpub.com/loi/jpm
https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care

This article is provided by The Village Pulse, The NYC Pain Specialists Blog.  Karan Johar, M.D. | Executive Editor, Cherry Lam | Chief Medical Editor, Sherry Chow | Assistant Healthcare Editor, Nathalia Schettino | Assistant Wellness Editor.  The information in these articles are written by our student interns interested in medical careers. As such please do not take the information described in these informational bulletins as medical advice. If you need treatment, please contact a certified medical health professional to address your issue.

Some quick thoughts on COVID-19 
and thoughts for the future
By Gary Smith

As we all know coronavirus has engulfed our society.  It seems we are going from one crisis to the next. This is not a good formula for what our future will look like.  Let us look at the historical significance and what it might mean in leading up to the current viral outbreak.  America is a reactive society, not a proactive society.  This can have serious consequences.  Pearl Harbor comes to mind.   We were warned by General Marshall that it would be attacked 10 days before and we chose to not respond.  Then in the early 2000’s we had SARS followed by MERS followed by Ebola. The potential for a serious virus outbreak with no treatments available portended to the future.  At one point we did respond by making preparations for a new outbreak.  But because we did not take it seriously, we later eliminated the safeguards that were put in place.

If we try to find some similarities to Passover, we could argue that we are seeing the 4th or 5th plague in the coronavirus.  So, the question that mounts in my mind is should we be paying attention to God’s messaging in our recent history and be proactive.  Will we see more plagues and will each one be worse than the last - as appears to be happening now?  My take is that we have become a society that buys things because we want them, not because we need them.  We have become a society that expects things, that does not appreciate what we have.  I also believe God is challenging us to prepare us for something much more serious. We need to pay attention to recent history, internalize the lessons of our traditions and prepare. 

We must respect this virus by wearing masks and rubber or other gloves.  Also, when you are inside a grocery store or around other people, wear plastic protective goggles or glasses.  Do not take coronavirus lightly. Please listen to what the scientists are saying.

Beyond the physical threats of coronavirus, our mental wellness is being challenged.  We had a “hearing people's voices” program on coronavirus and how it affects anxiety and depression.  Mental Illness has exploded upward in the last 2 months.  Suicide rates are on a rapid rise with our overworked health care workers.  Prior, mental illness was high at 1 in 4 people.  Now the numbers are much higher.  The FJMC/FJL committee is addressing this issue through sensitizing our synagogue communities.

Governmental leadership has been slow to act and has been reactive not proactive. We can argue that the numbers are much higher because so many people have not been tested yet or not tested twice. Why is only part of the country on lockdown and not all the country? We know that Germany will provide us with the test kits we need.  They provided South Korea with over 10,000 tests a day.  South Korea was able to bring the pandemic there down fairly quickly because they were proactive with a plan and a protocol for success.

The coronavirus pandemic can be used as an opportunity for each of us to become more connected to our communities. Minyans online are enjoying numbers they have never seen.  Our creativity as a people will be unprecedented as new models for living and praying are developed, permanently changing our lives.  Online telemedicine is exploding; online psychology and psychiatry are also becoming part of life.  We might as well get used to it and embrace it.  What will that mean for sports? For shows i.e. Broadway?  for ballet?  and symphony? and for our museums?

Let’s discuss this among ourselves – I am sticking my neck out proactively.  How about you? If you would like to participate, we can run an online webinar to share our visions.  If interested, tell Alan Budman, VP of Training, of your interest and we will be glad to talk more about this.  For more information and discussion please contact Gary Smith, gsmith@fjmc.org.

Some quick thoughts on the Mental Wellness Initiative
By Gary Smith

1 in 4 people has some form of mental illness.  That number is rising rapidly.  Your FJMC /FJL are addressing this issue by forming a committee to identify the demographic and by working on Awareness, Education, and Prevention.  It is our hope that we can make some small difference.  If we can destigmatize mental illness in our synagogues so that we can discuss this in a more open environment, this will move our synagogues to be more welcoming organizations, We are encouraging our members and regions to ask their rabbis to consider specifically including mental illness issues in mi shaberachs. Mobilizing our members and all of us being creative in bringing this initiative to our synagogues and communities in multiple ways will create a Keruv (welcoming) effect and help us begin to make a difference.  You will hear more and more in subsequent issues.  

What are safe investments and where should your money be invested?
By Gary Smith

Magical companies are ones that can compound top-line growth at massive scale, improve margins, allocate capital efficiently, and do the right thing for all their constituencies.

We are in a critical phase of our economic cycle.  What you are about to read is a laypersons thoughts about investing in this environment.  Most important is to have at least 20 % of your portfolio in cash as well as enough cash to survive for 3-6 months.  Invest 1-5 % in gold and precious metals. This was a very prudent move for your FJMC FOUNDATION FOR JEWISH LIFE. These buffered our portfolio during this downturn.  This is a perfect time to decide where you want to be invested.  Keep cash and be ready to invest when the timing is right. It might be in 3 days, 3 months or 1 year.

The government is making a new gift of 2 trillion dollars and likely more will follow.  Along with our 4.5 trillion-dollar debt, student loans, auto loans and mortgage loans this has put the US Government over 16 trillion dollars in debt.  Are we mortgaging the future of our kids to save the present?  Will this contribute to the ultimate bursting of the bubble and lead to not only a possible depression but severe inflation.  If you believe we will have inflation, then consider gold and precious metals as a quality investment. 

Earlier, I suggested the best place for money is in cash and precious metals.  With the drop in the market, it is time to begin nibbling on stocks or stock ETFs.  It is usually impossible to call the bottom, nor should you try.  But look at the trends.  Is the Bull market still alive?  What should we nibble on?  I am so in favor of investing in what is called FOREVER STOCKS.  These are stocks that you will hold forever that have steady growth, a product that everyone needs, and are capital-efficient companies.  Capital-efficient stocks have the unique ability to grow sales and earnings without requiring matching growth in capital investments.  As a result, they can increase their dividends (or share buybacks) much faster than other companies.

Growing wealth mostly is the result of the time you take to research and make investments in capital-efficient companies that allow you to sleep at night.  We are talking about some of Warren Buffet’s best and longest-term investments.  Some names are Coke, Hershey, McDonald's, Microsoft, American Express, Johnson and Johnson, Facebook, Starbucks, WR Berkley.  QQQ is an ETF that encompasses Microsoft, Facebook, Google, Amazon, and all the top technology stocks.  This type of investing is not only proven but will enrich your life as well as your kids and grandkids 

I hope you have enjoyed this discussion.  I know that this is a lay person’s view but hopefully this will give you some thoughts to discuss with your money manager. Email me at gsmith@fjmc.org or our editor Richard Gray  rwgray1@gmail.com

Neurodegenerative Disease and the Burden on Caregivers
By Steven Mandel MD, Heidi Mandel PhD LMSW, Gayatri Devi MD, MS, FACP, FAAN

Sally, a 68-year-old trim and petite brunette is married to Bob, 72, who has developed Alzheimer’s disease.  A soft-spoken man, Bob, an accountant who handled all family finances, is now unable to do so.  Sally has had to step in. Their two grown children live in other states and as Sally put it, “They have their own lives, I don’t want to bother them. Still,” she continued wistfully after a pause, “it would be nice if they called a little more often.”

Sally has had to not only take over all finances, she now makes all decisions and feels somewhat alone, despite the love lavished on her by her husband.  “I didn’t know from a bill,” Sally said, “Bob took care of everything. Now, I am stumbling through.”  One out of nine people over the age of 60 have dementia as do one out of three people over the age of 80, the majority being either Alzheimer’s disease or a mixed dementia from Alzheimer’s and stroke.

The portion with mild cognitive impairment has:
1. concern about changes in cognitive ability,
2. impairment in one or more cognitive domains, more than expected for age and education.
3. preservation of independence in functional abilities
4. no significant in-social or occupational loss of functioning
5. one third progressing to dementia in 5 years. 

As the disease progresses, there is memory loss, impairment in planning and solving problems, difficulty with familiar tasks, challenges to understanding visual information, impaired speaking and writing, misplacing of things, poor judgment and decision making, withdrawal from social interaction, difficulty driving, changes in personality and mood, and delirium and psychosis.  In the severe stages, there may be a need for assistance with activities of daily living, sleep disorders, delusions, wandering, poor communication and inability for self-care and personal hygiene.

There may be amnestic and no amnestic characteristics.  Amnestic means recall and learning new information.  Non-amnestic means problems with language, word-finding, visual-spatial, judgment and problem-solving.

Risk Factors that may increase the probability of neurodegenerative disease include hypertension, high lipids (LDL), cardiovascular disease, diabetes, obesity, peripheral arterial disease, sedentary lifestyle, lack of exercise, head trauma, medications to Include benzodiazepines, smoking, air pollution, pesticides, genetic predisposition, low educational status, physical frailty, poor social support, and diminished hearing.  Increasing age and lower educational level and diagnosis of hypertension and diabetes are associated with an increased basal metabolic index that is associated with worse cognitive function and poor verbal fluency.

Differential diagnosis of neurogenerative disease includes Lewy Body disease, Alzheimer’s with prominent memory loss, corticobasal  degeneration, Creutzfeldt-Jacob disease,  frontotemporal dementia, hypothyroidism, neoplasm, normal pressure hydrocephalous and atherosclerotic cardiovascular disease.  Vascular dementia accounts for 20% of neurodegenerative disease.

Factors that may improve cognition include:
1.       Cognitive training programs
2.       Exercise
3.       Healthy diet – Mediterranean diet, MIND diet
4.       Social connection
5.       Limiting alcohol
6.       Not smoking
7.       Management of stress
8.       Learning new skills

Caregivers can be family members, significant others or professionals.  Burdens on caregivers include poor nutrition, high levels of stress anxiety and depression, family conflicts about sharing responsibilities and treatment management and lack of sleep.

For professionals to be qualified to care for those with dementia they need to understand how the disease progresses and what to expect.  Also, how to communicate best with the doctor and medical team, how to increase the quality of life for the patient and the family including walks, music, games, and adequate sleep.  As the disease progresses, there may be delirium and psychotic behavior that may challenge the coping capacities of the caregivers such as unpredictable behavior including wandering and resistance to accepting care.

Caregivers for those with dementia suffer a higher level of stress and depression because of the progressive nature of dementia. Caregivers suffer from physical, financial and emotional burdens.  There are three stages for caregiver help.  In the early stage of dementia, the caregiver helps the family member maintain independence, establishes routines, such as sleep, exercise, diet, and maintaining activities that they enjoy. In the middle stage, the caregivers help with dressing, day to day functioning, and emotional stability.  In the late stage, caregivers help with personal hygiene issues such as incontinence, and with emotional dysfunctions such as delusions and wandering.

The caregiver needs an approach of compassion and respect for the dignity of the family member because of the unpredictability of the behavior patterns as the disease progresses.

Positive strategies to manage caregiver burden include:
1.        Seeking support from your own or professional network, such as friends, family, community support groups, and the health and mental health teams.
2.       Direct physical and emotional reducing behaviors, such as meditation, yoga, and breathing exercises.
3.       Eating well and getting sufficient sleep and managing one’s own medical problems well.
4.       Other local and community resources like meal delivery, transportation, home health aides and additional medical advice resources.

Gayatri Devi, MD, MS, FACP, FAAN is Clinical Professor of Neurology at Downstate Medical Center, Attending Physician at Lenox Hill Hospital and Northwell Health Director at Park Avenue Neurology.