Boston Globe opinion piece on decision aids for dying patients on end-of-life care options

Angelo Volandes, MD, a physician at Massachusetts General Hospital, wrote an opinion piece published in the Boston Globe today.  He tells the story of a patient dying of cancer, with whom he brought up the topic of end-of-life care options:

“For the next hour I introduced a vocabulary as foreign to her as spondee and trochee were to me. Life-prolonging treatment and CPR, ventilators and intubation, DNR and DNI — terms that she would need to learn quickly. Unfortunately, I was trying to teach her a new lexicon in the midst of the haze of nausea and hospitalization.

Dazed and confused, they looked at me blankly. Words often fail us in medicine. How could I explain these abstract ideas and treatments? Most patients think hospitals and medical interventions look like what they see on television where most survive CPR beautifully; the truth is most people with advanced incurable cancer do not do well with these interventions and often suffer at the end of life.

Finally, I tried a different approach. “Do you mind if we take a walk through the ICU?” I said.

If words failed me, perhaps seeing the intensive care unit would help. Seated in a wheelchair …Helen got a tour of the ICU, where she saw an intubated patient on a ventilator and a patient having a large intravenous line placed. Her decision-making would be informed by what she saw, instead of having to imagine what my terms really meant.

When we arrived back at her room, she looked at me and said, “Words, words, words. . . Angelo, I understood every word that you said — CPR and breathing machines, but I had no idea that is what you meant.”

I was reprimanded by the ICU staff for bringing Helen and her husband on that tour, but I was quickly forgiven. Evidently, many felt, like me, that patients deserve to be educated in order to make informed decisions about end-of-life choices.”

That was years ago when he was a medical resident.

Today, he goes on to explain, he and others use video decision aids to help people think about care options.

View the original article here

Boston Globe opinion piece on decision aids for dying patients on end-of-life care options

Angelo Volandes, MD, a physician at Massachusetts General Hospital, wrote an opinion piece published in the Boston Globe today.  He tells the story of a patient dying of cancer, with whom he brought up the topic of end-of-life care options:

“For the next hour I introduced a vocabulary as foreign to her as spondee and trochee were to me. Life-prolonging treatment and CPR, ventilators and intubation, DNR and DNI — terms that she would need to learn quickly. Unfortunately, I was trying to teach her a new lexicon in the midst of the haze of nausea and hospitalization.

Dazed and confused, they looked at me blankly. Words often fail us in medicine. How could I explain these abstract ideas and treatments? Most patients think hospitals and medical interventions look like what they see on television where most survive CPR beautifully; the truth is most people with advanced incurable cancer do not do well with these interventions and often suffer at the end of life.

Finally, I tried a different approach. “Do you mind if we take a walk through the ICU?” I said.

If words failed me, perhaps seeing the intensive care unit would help. Seated in a wheelchair …Helen got a tour of the ICU, where she saw an intubated patient on a ventilator and a patient having a large intravenous line placed. Her decision-making would be informed by what she saw, instead of having to imagine what my terms really meant.

When we arrived back at her room, she looked at me and said, “Words, words, words. . . Angelo, I understood every word that you said — CPR and breathing machines, but I had no idea that is what you meant.”

I was reprimanded by the ICU staff for bringing Helen and her husband on that tour, but I was quickly forgiven. Evidently, many felt, like me, that patients deserve to be educated in order to make informed decisions about end-of-life choices.”

That was years ago when he was a medical resident.

Today, he goes on to explain, he and others use video decision aids to help people think about care options.

View the original article here

Opinion: The Human Disaster of Unemployment

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In 2007, before the Great Recession, people who were looking for work for more than six months — the definition of long-term unemployment — accounted for just 0.8 percent of the labor force. The recession has radically changed this picture. In 2010, the long-term unemployed accounted for 4.2 percent of the work force. That figure would be 50 percent higher if we added the people who gave up looking for work.

Long-term unemployment is experienced disproportionately by the young, the old, the less educated, and African-American and Latino workers.

While older workers are less likely to be laid off than younger workers, they are about half as likely to be rehired. One result is that older workers have seen the largest proportionate increase in unemployment in this downturn. The number of unemployed people between ages 50 and 65 has more than doubled.

The prospects for the re-employment of older workers deteriorate sharply the longer they are unemployed. A worker between ages 50 and 61 who has been unemployed for 17 months has only about a 9 percent chance of finding a new job in the next three months. A worker who is 62 or older and in the same situation has only about a 6 percent chance. As unemployment increases in duration, these slim chances drop steadily.

The result is nothing short of a national emergency. Millions of workers have been disconnected from the work force, and possibly even from society. If they are not reconnected, the costs to them and to society will be grim.

Unemployment is almost always a traumatic event, especially for older workers. A paper by the economists Daniel Sullivan and Till von Wachter estimates a 50 to 100 percent increase in death rates for older male workers in the years immediately following a job loss, if they previously had been consistently employed. This higher mortality rate implies that a male worker displaced in midcareer can expect to live about one and a half years less than a worker who keeps his job.

There are various reasons for this rise in mortality. One is suicide. A recent study found that a 10 percent increase in the unemployment rate (say from 8 to 8.8 percent) would increase the suicide rate for males by 1.47 percent. This is not a small effect. Assuming a link of that scale, the increase in unemployment would lead to an additional 128 suicides per month in the United States. The picture for the long-term unemployed is especially disturbing. The duration of unemployment is the dominant force in the relationship between joblessness and the risk of suicide.

Joblessness is also associated with some serious illnesses, although the causal links are poorly understood. Studies have found strong links between unemployment and cancer, with unemployed men facing a 25 percent higher risk of dying of the disease. Similarly higher risks have been found for heart disease and psychiatric problems.

The physical and psychological consequences of unemployment are significant enough to affect family members. The economists Kerwin Charles and Melvin Stephens recently found an 18 percent increase in the probability of divorce following a husband’s job loss and 13 percent after a wife’s. Unemployment of parents also has a negative impact on achievement of their children. In the long run, children whose fathers lose a job when they are kids have reduced earnings as adults — about 9 percent lower annually than children whose fathers do not experience unemployment.

We all understand how the human costs can be so high. For many people, their very identity is their occupation. Few events rival the emotional strain of job loss.

IT seems clear that neither political party was prepared to deal with the crisis of long-term unemployment. In spite of the severity of the downturn, there was a general expectation that the economy would bounce back, as it had after previous downturns.

Some countries that were more familiar with long-term unemployment, notably Germany, were much better prepared to deal with the fallout from the crisis. The German government aggressively pushed work-sharing measures. This meant that instead of workers’ being laid off and receiving unemployment benefits, the German government helped companies keep employees, working fewer hours, on their payrolls by subsidizing their wages with the money saved on unemployment benefits.

The result of this policy is that Germany’s unemployment rate is now lower than it was at the start of the downturn, even though its growth has been no better than ours.

Dean Baker is co-director of the Center for Economic and Policy Research. Kevin Hassett is director of economic policy studies at the American Enterprise Institute.

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Opinion: Fables of Wealth

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THERE is an ongoing debate in this country about the rich: who they are, what their social role may be, whether they are good or bad. Well, consider the following. A 2010 study found that 4 percent of a sample of corporate managers met a clinical threshold for being labeled psychopaths, compared with 1 percent for the population at large. (However, the sample was not representative, as the study’s authors have noted.) Another study concluded that the rich are more likely to lie, cheat and break the law.

The only thing that puzzles me about these claims is that anyone would find them surprising. Wall Street is capitalism in its purest form, and capitalism is predicated on bad behavior. This should hardly be news. The English writer Bernard Mandeville asserted as much nearly three centuries ago in a satirical-poem-cum-philosophical-treatise called “The Fable of the Bees.”

“Private Vices, Publick Benefits” read the book’s subtitle. A Machiavelli of the economic realm — a man who showed us as we are, not as we like to think we are — Mandeville argued that commercial society creates prosperity by harnessing our natural impulses: fraud, luxury and pride. By “pride” Mandeville meant vanity; by “luxury” he meant the desire for sensuous indulgence. These create demand, as every ad man knows. On the supply side, as we’d say, was fraud: “All Trades and Places knew some Cheat, / No Calling was without Deceit.”

In other words, Enron, BP, Goldman, Philip Morris, G.E., Merck, etc., etc. Accounting fraud, tax evasion, toxic dumping, product safety violations, bid rigging, overbilling, perjury. The Walmart bribery scandal, the News Corp. hacking scandal — just open up the business section on an average day. Shafting your workers, hurting your customers, destroying the land. Leaving the public to pick up the tab. These aren’t anomalies; this is how the system works: you get away with what you can and try to weasel out when you get caught.

I always found the notion of a business school amusing. What kinds of courses do they offer? Robbing Widows and Orphans? Grinding the Faces of the Poor? Having It Both Ways? Feeding at the Public Trough? There was a documentary several years ago called “The Corporation” that accepted the premise that corporations are persons and then asked what kind of people they are. The answer was, precisely, psychopaths: indifferent to others, incapable of guilt, exclusively devoted to their own interests.

There are ethical corporations, yes, and ethical businesspeople, but ethics in capitalism is purely optional, purely extrinsic. To expect morality in the market is to commit a category error. Capitalist values are antithetical to Christian ones. (How the loudest Christians in our public life can also be the most bellicose proponents of an unbridled free market is a matter for their own consciences.) Capitalist values are also antithetical to democratic ones. Like Christian ethics, the principles of republican government require us to consider the interests of others. Capitalism, which entails the single-minded pursuit of profit, would have us believe that it’s every man for himself.

There’s been a lot of talk lately about “job creators,” a phrase begotten by Frank Luntz, the right-wing propaganda guru, on the ghost of Ayn Rand. The rich deserve our gratitude as well as everything they have, in other words, and all the rest is envy.

First of all, if entrepreneurs are job creators, workers are wealth creators. Entrepreneurs use wealth to create jobs for workers. Workers use labor to create wealth for entrepreneurs — the excess productivity, over and above wages and other compensation, that goes to corporate profits. It’s neither party’s goal to benefit the other, but that’s what happens nonetheless.

Also, entrepreneurs and the rich are different and only partly overlapping categories. Most of the rich are not entrepreneurs; they are executives of established corporations, institutional managers of other kinds, the wealthiest doctors and lawyers, the most successful entertainers and athletes, people who simply inherited their money or, yes, people who work on Wall Street.

MOST important, neither entrepreneurs nor the rich have a monopoly on brains, sweat or risk. There are scientists — and artists and scholars — who are just as smart as any entrepreneur, only they are interested in different rewards. A single mother holding down a job and putting herself through community college works just as hard as any hedge fund manager. A person who takes out a mortgage — or a student loan, or who conceives a child — on the strength of a job she knows she could lose at any moment (thanks, perhaps, to one of those job creators) assumes as much risk as someone who starts a business.

Enormous matters of policy depend on these perceptions: what we’re going to tax, and how much; what we’re going to spend, and on whom. But while “job creators” may be a new term, the adulation it expresses — and the contempt that it so clearly signals — are not. “Poor Americans are urged to hate themselves,” Kurt Vonnegut wrote in “Slaughterhouse-Five.” And so, “they mock themselves and glorify their betters.” Our most destructive lie, he added, “is that it is very easy for any American to make money.” The lie goes on. The poor are lazy, stupid and evil. The rich are brilliant, courageous and good. They shower their beneficence upon the rest of us.

Mandeville believed the individual pursuit of self-interest could redound to public benefit, but unlike Adam Smith, he didn’t think it did so on its own. Smith’s “hand” was “invisible” — the automatic operation of the market. Mandeville’s involved “the dextrous Management of a skilful Politician” — in modern terms, legislation, regulation and taxation. Or as he versified it, “Vice is beneficial found, / When it’s by Justice lopt, and bound.”

An essayist, critic and the author of “A Jane Austen Education.”

This article has been revised to reflect the following correction:

Correction: May 16, 2012

An earlier version of this article misstated the findings of a 2010 study on psychopathy in corporations. The study found that 4 percent of a sample of 203 corporate professionals met a clinical threshold for being described as psychopaths, not that 10 percent of people who work on Wall Street are clinical psychopaths. In addition, the study, in the journal Behavioral Sciences and the Law, was not based on a representative sample; the authors of the study say that the 4 percent figure cannot be generalized to the larger population of corporate managers and executives.

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Was Tim Burton Ever A Good Director? (OPINION)

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With a title like that, I'm sure to get a lot of hate for even suggesting such a notion.

But here's the thing: I loved Tim Burton. He was my absolute favorite director until around 2001. The worlds he created held my attention in a deeper way than other filmmaker's. The oddball and macabre design, along with the melancholy atmosphere, were unlike anything I had seen in movies. It was as fantastical in imagination as any blockbuster, and it felt more ethereal and personal than the "Hollywood" spectacle of a Spielberg or Zemeckis film. He introduced me to ideas of retro kitsch, spooky fringe and proudly holding onto timeless obsessions of your youth.

Burton is one of those early influences in my life that made me become a passionate movie lover. I can catch "Beetlejuice" or "Pee-wee's Big Adventure" at any moment on TV and immediately get sucked back into them. Batman, Jack Skellington, Martians that explode at the sound of Slim Whitman -- I was (and still am) a head-over-heels fanboy for those cinematic adventures. But now I look at those movies and hold them in high regard in spite of Tim Burton.

Tim Burton is not the filmmaker he used to be. The haunting emotional resonance of an early project like "Edward Scissorhands" does not exist in something like 2010's "Alice in Wonderland," or the recently released "Dark Shadows." (And if you think it does, please feel free to explain.) Since 2001, he's been more content playing the Hollywood game: trying to sell the public on pre-packaged, risk-free commercial entertainment that looks pretty, has distinct colors, and usually features Johnny Depp exhibiting some kind of quirk for ninety-minutes. These projects are the cinematic equivalent of cotton candy: They're not meant to be "deep" or "profound," nor are they trying to use the artform of movie-making to uncover any new truths about the human condition. Their sole purpose is to get you to pay twelve dollars to laugh and be distracted from your life. It's as interchangeable and disposable as "Battleship" or those Geico commercials with the excited pig.

How did Tim Burton become such a money-chasing hack? How could someone who was so unique become so manufactured? There are only two potential answers. One: he's much more cynical than his public persona lets on. He's a businessman, who is perfectly content selling his brand to the young (and young at heart) outcasts of society with a few token themes of "loneliness," and then wrapping it all in a line of merchandise ready for the new season at Hot Topic. He doesn't care if it's an old drawing, a trading card set, a '70s soap opera or a comic book; if it's "goth," then he wants to sell it to you. If that's the case, then he doesn't deserve the adulation that his fanbase has given him. The only other option is this: he was never that good to begin with.

When he was a young and hungry director, Burton wasn't given free rein to do whatever he wanted. He had to compromise with producers, writers, actors and scores of other people involved with a movie. Making a film is a collaborative process; no one person is responsible for a film's perfection, even on the greatest movies of all time. But now that he's "Tim Burton" -- and delivered billions on box-office profits -- he's not going to be reined in. He's surrounded by producers who sign blank checks for him to do his "Tim Burton" thing, then he casts his best friend and his girlfriend in his movie. He's so ensconced in his little bubble that he'll never hear "that's a bad idea" or be pushed to find new ways to entertain. Looking at the last decade of his work, it's clear that if he's this one-note, then all the past glory he's received needs to be given to other people.

So let's stop pretending and call it like it is: Tim Burton is a really good art designer. And that's it. He's great at coming up with visual graphics that translate to impressive costumes, makeup, scenery and special effects. That's an impressive skill set, but it doesn't make him a good director. "Directing" a film comes with a lot of storytelling responsibilities that go beyond making everything look cool. Burton's been handed a rare opportunity to tell stories to a global audience, and all he does is make toy commercials. Why do I have to pretend like he's anything better than that?

For further proof, let's take a look back at each of Burton's projects

"Pee-wee's Big Adventure"
This character (and movie) belongs to Paul Reubens (not to mention co-writers Phil Hartman and Michael Varhol). While Burton helped translate the Pee-wee persona to the big screen, this was a passion project for the film's star.

"Beetlejuice"
Michael McDowell was the one who brought the script to Burton; later Larry Wilson and Warren Skaaren developed the story further. The movie also sports an impressive cast, from Alec Baldwin to Winona Ryder to Jeffrey Jones. And the titular character might be the perfect demonstration of Michael Keaton's manic comedic timing.

"Batman"
Again, Burton had nothing to do with the story -- the script is again credited to Sam Hamm and Skaaren (plus several uncredited rewrites). And once more Keaton was spotlighted in a leading role, this time a risky departure from his usual character type. Plus, it starred Jack freakin' Nicholson, who had so much presence and control over his character, he could basically dictate the shooting schedule around Lakers games.

"Edward Scissorhands"
Edward started as a drawing from Burton's teenage years, and the task of creating an actual story was handed off to Caroline Thompson, a novelist who proved to be very adept at translating fairy tales to the big screen (her later credits include "Black Beauty," "The Secret Garden" and a TV version of "Snow White.") A young Johnny Depp signed on to take his first big acting risk, and he was surrounded by Oscar-winning talent like Dianne West and Alan Arkin, plus the legendary Vincent Price.

"Batman Returns"
Burton was not interested in directing the film, but only signed on to get "Scissorhands" greenlit. Again, he had nothing to do with the script, and the extravagant production was filled with effects by wizards like Stan Winston.

"The Nightmare Before Christmas"
This is a contentious one in some fan circles because Burton didn't even direct and he regularly receives credit like he does. "Nightmare" started as a three-page poem from the '80s; the movie script was developed by Caroline Thompson again and the musical portions came from long-time creative partner Danny Elfman. The whole affair was directed under the eye of Henry Selick, one of the most successful stop-motion animators in history.

"Ed Wood"
The genesis of this idea came from screenwriters Scott Alexander and Larry Karaszewski, who have gone on to pen biopics "The People vs. Larry Flynt" and "Man on the Moon." The project was originally going to be directed by "Heathers" director Michael Lehmann, but he had to drop out at the last minute due to scheduling conflicts. Burton took over and filmed the first draft, as is. The film was buoyed by performances from Depp, Bill Murray and an Oscar-winning turn from Martin Landau.

"Mars Attacks!"
The goal of this movie was to pay tribute to B-movies from decades past, and it accomplished it: "Mars" was the first commercial and critical disappointment of his career. But if it's not your aim to make a good movie, is it considered a failure?

"Sleepy Hollow"
The film started as a low-budget slasher from the writer of "Seven" and Kevin Yagher, a special effects artist looking to make his directorial debut. After Yagher lost the job due to creative differences, Burton signed on, having just removed himself from the infamous "Superman" debacle at Warner Bros.

"Planet of the Apes"
The poorly-reviewed and forgotten remake spent years in development hell before Burton signed on, amid criticism that he was a "hired gun" for 20th Century Fox.

"Big Fish"
Screenwriter John August adapted the unpublished novel "Big Fish: A Novel of Mythic Proportions" and spent years working with Steven Spielberg, who was planning on directing. Burton signed on after Spielberg had to drop out. And don't forget August's words were delivered by critically acclaimed actors like Albert Finney, Ewan McGregor and Jessica Lange.

"Charlie and the Chocolate Factory"
This second attempt at adapting Roald Dahl's book came from Dahl himself, who spent years trying to get a film version that was closer to his vision than the 1971 family classic. After many directors toyed with the idea of working on "Wonka," Burton signed on with August and Depp, adding their own new backstory to the candy-maker and receiving criticism for Depp's eccentric Michael Jackson-like performance.

"The Corpse Bride"
Burton shared co-directing credits with Mike Johnson, a stop-motion animator, and screenwriting credits again went to August and Caroline Thompson.

"Sweeney Todd: The Demon Barber of Fleet Street"
Burton replaced Sam Mendes, who was working directly with Broadway composer Stephen Sondheim. The film adaptation was scripted by the multi-time Oscar-nominated John Logan, while Sondheim remained as a creative consultant overseeing the production.

"Alice in Wonderland"
Burton signed a deal with Disney to make two 3D films; with Disney writer Linda Woolverton on board, Burton tackled "Alice" because he never felt an "emotional connection" to Lewis Carroll's story. His re-worked tale, that involved effects-laden battle scenes, received some of the worst reviews of his career.

"Dark Shadows"
For his latest effort, Burton hired Seth Grahame-Smith to pen the adaptation of a cult 70s soap opera. Prior to his first screenplay work, Grahame-Smith was famous for writing a "Spider-Man" handbook, "The Big Book of Porn" and the literary mash-ups "Pride and Prejudice and Zombies" and "Abraham Lincoln: Vampire Hunter," which combine one thing that was already successful with another thing that was already successful.

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