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by | April 16, 2014 · 5:22 pm

Using advance directives as tools

Guest Post by Dan Morhaim

The tools are here. We just need to use them.

These tools offer something rare and important in our modern medical system: an opportunity to exert influence. I am talking about advance directives, the powerful instruments that allow each of us to manage the final chapter of life in a dignified manner and according to our own wishes and values.

As an emergency medicine physician, I’ve seen scenarios like this one all too often: An ambulance brings to the hospital a frail, elderly patient with shortness of breath, irregular heartbeat, and plunging blood pressure. The wasted limbs indicate years of incapacitation, and the medical record reveals a long history of dementia. As we work to restore stability, probing paper-thin skin for a vein, the patient suddenly goes into cardiac arrest.

The patient does not have an advance directive or a Do Not Resuscitate (DNR) order, so the ER team goes into full CPR mode, cracking brittle ribs with every chest compression. If the team’s efforts are “successful,” the patient will endure suffering that may last for the rest of his or her life.

We know that too much of this “care” is futile, hurtful, and wasteful. While some will opt to “do everything” no matter how painful the treatment or how unlikely the chance for recovery, most people do not want to die in this manner.

There comes a time when most of us would choose to allow a natural death rather than use medical technology to prolong life for what is usually only a few extra hours, days, or weeks. But when that moment comes, we are often not in a position to speak for ourselves. That’s why we need advance directives, which are free, straightforward, easily available forms that are legal in every state.

Americans cherish the right to make their own medical decisions. In light of our ardent individualism, it’s puzzling that so few of us exercise this right when it comes to something most of us will face: medical care at the end of our lives. (A study from the Johns Hopkins Bloomberg School of Public Health showed that only about one-third of us have completed advance directives.)

Care at the end of life involves making some deeply personal choices. Who should make them? Doctors? Government? Insurance companies? Hospitals? Ethics committees? Religious institutions? As both a physician and a state legislator, I believe that the operative values should be the patient’s. When patients haven’t expressed their wishes or designated someone who can act for them if they’re incapacitated, controversy and painful family upheaval can ensue.

While cost is not the primary reason to have an advance directive, saving money is one of its consequences. Medicare estimates that 25-30 percent of its spending goes for care during the last six months of life. The costs to Medicaid programs and private insurance are equally staggering.

As the baby boom generation reaches its senior years, new lifesaving medical treatments are devised, and our health care system confronts a crisis of affordability, we, all of us, need to take time to record our end-of-life decisions.

I hope that, one day, completing advance directives will become as routine as renewing your driver’s license. If advance directives were to become the norm—if, say, 80 percent of adult Americans had them—we could offer more personalized and humane care for far less money. Respecting individual rights is the right way to reduce health care costs.

Remember: only you can complete your advance directive. No one can do it for you. Get the forms, fill them out, share with family, friends, and physicians as appropriate and then encourage everyone you know to do the same. This is not a tool just for “old people,” either. It’s a tool for everyone, to specify the kind of care you want as you approach the end of life, whenever that occurs.

The tools are here. We just need to use them.

And what better way to get started than on April 16, National Health Care Decisions Day?

Dan Morhaim and Brent Pawlecki, M.D., Medical Director Goodyear Tire Company  have written a column  for Health Affairs on the role employers can play in promoting advance directives.

morhaimDan Morhaim, M.D., is an adjunct professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, Deputy Majority Leader of the Maryland House of Delegates, and the author of The Better End: Surviving (and Dying) on Your Own Terms in Today’s Modern Medical World. He is board certified in emergency medicine and internal medicine.


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Filed under For Everyone, Geriatrics and Gerontology, Health and Medicine, Public Health

Peter Filkins on Writing Poetry

Guest post by Peter Filkins

Randall Jarrell said that writing poetry was like walking across a field at night while hoping to be struck by lightning. While the fickle and unpredictable nature of genuine inspiration can be much like that, there are also poems that you know are sort of there and waiting to be written, but which need the slow stewing of time and experience to bring them to full realization. “A Stand of Maple” was just such a poem for me, for I knew I had its essential subject matter several years before I wrote it. Traveling often on a back road through the hills of western Massachusetts, I can’t even recall when I first admired a long allée of tall sugar maples lining both sides of the road, a heaving surge of stone wall lacing together their sturdy trunks, and sap buckets nailed to them each spring. I would often say to myself, “Now that’s something worth writing about,” and then tuck it away in a mental file of images and subjects I wanted to get to, but without any essential bit of language having offered the right inroad into the experience.

And then one day at home, for whatever reason, the venture of a poem about them seemed worth it. In fact, by then the maples were much the worse for wear, and it was starting to become clear that they would not be around all that much longer. I suppose that glimpse is what even gave rise to the analogy of the sapping tubes as life support, as well as how novel their very existence was after having seen who knows how many New England winters. Still, I did not want it to be a poem about loss or mortality, for I had enjoyed the life of those trees for so very long, and it was that life that indeed came to seem wondrous, “intrepid and insensible,” even “unlikely.” Yet I recall being most satisfied with thinking of their very nature as “irrecusable,” that they were simply there, bearing a kind of silent witness to the possibility of beauty and hardiness and the perception of both, as well the ironic offering culled each spring from their haggard trunks, “amber on the tongue” being, for me, the only real way to convey the sensory integrity of maple syrup and what it means to be alive and lost to its sweetness.


A Stand of Maple

Either side of the pot-holed postal road
they rise, imperious in their haggard bark
against a stone wall spilling boulders like coins
among caramel-colored rays of winter sun
conceding snowdrift shadow its ice-bound blue.
Soon sap will fill them, swelling sagging veins
of plastic tubing stretched like life support
above mercurial rivulets of melting snow,
while nearby and palpable, hints of green
will rouse a meadow to swaying life again.
And yet for now, frozen in this aching cold,
recalcitrant as a riddle, branches whistling
in a razor wind, who could possibly know
their future a season hibernating in starches
released by fire boiling their sugars clean?
How intrepid and insensible, how unlikely
the world can seem, an empty length of road
boring through maples, bitter capillaries of cold
promising sweetness, irrecusable the thrum
of buckets in springtime, amber on the tongue.

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filkinsPeter Filkins is a poet who teaches writing and literature at Bard College at Simon’s Rock. He is the author of What She Knew and After Homer as well as the chapbook Augustine’s Vision. He has also translated the poetry and novels of Ingeborg Bachmann and the novels of H. G. Adler. Filkins’s most recently published collection is The View We’re Granted.

Peter Filkins will give a poetry reading at the Newbury Port Literary Festival on Saturday, April 26th, 1:00 pm.  The reading and book signing is at Central Congregational Church Social Hall.

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Poetry as presence

During April, National Poetry Month, we asked several JHU Press poets to reflect on their art. Brian Swann shares his thoughts and some selections from his latest collection, In Late Light.

Guest post by Brian Swann

The kind of poem that means the most to me begins in wonder. Something we might have seen a hundred times catches the attention and holds it: a tree, birds, horses in a field, or something we didn’t know we had remembered bubbles up. Then the poem spins out reverberative images with the appearance and feel of permanence; it embodies a sensation, making a moment valuable in a throw-away world.

A poem reflects light from the back of the eye so you can see in the dark, like a lion. But even when it is complete, a poem can never tell all there is to tell. And it is always hiding something, the way a dream does.

As Paul Ricoeur has noted, a poem becomes “the representation of presence.” The ancient world was filled with presence, as are traditional tribal cultures today. Poetry tries to call things back from the positivistic brink, away from what Rilke called “America,” where “empty, indifferent things pour over us.” Today, everywhere is America. A poem calls to the world’s beautiful strangeness, the uniqueness of everything and the way things are related and linked in a world at once us, and not us. The poetry I respond to is atavistic. Poetry fights a losing battle, but one well worth fighting.

The Horses

As I reach across I’m
taller than the backs
I stroke before they’ll move
away for as good a reason
as they stayed, down
the steep hill that’s
their meadow of thin grass,
more thyme and rock
than grass, brambles and
this stone wall I’m standing on
that for a while keeps us
all together, I and these horses
so large they’ll leave behind
their silhouettes as mountains,
where now as I stroke their
huge heads and necks like pillars,
gentle muzzles and soft mouths,
they stand so still under the great maple
that I can hear them breathe
and I talk to them as if they
could understand more than
I can, as if they don’t know
that what I’m saying to them
has no other purpose than
to keep them with me and
me with them here until
I have to turn carefully
around on these loose stones,
step down and find my way
back through the darkening woods.

A Typology of Birds

Typology relates to the future, and is consequently

related primarily to faith and hope, and vision.

—Northrop Frye, The Great Code


I have been here some time where
single things pull curtains around them
and the loneliest fall into their own breath.
But in spring I watched water
turn gravity on its head, and saw birds
quiver like tuning forks. Now
summer’s going, when a crack appears
in the sky they’ll fly into it. Circling
stars, they’ll spin out to each other
through nights that give way to them,
following lines to the horizon and then
over into a nothing like a prayer
they know the answer to, and out beyond,
whirling away, and I’ll know they’re
up there, among leave-takings and remainders,
their solemn eyes a kind of light even
at noon, and the same bells I heard by day
going on and on, lighter than shapes,
more persistent than appetite, as if one could
break through to that side and reassure

Making It Out

All over these mountains are huge stone walls, piled up by men
With oxen, tackle, crowbars, and brute will. Trees grow right
Through them, and they still stand. When you hike these woods
They come in at all angles, out of nowhere, cross and re-cross,
Holding whole hillsides up, tracing some invisible plan,
Giving you something to go by. But try following and likely
As not you’ll stop and look around and say Where am I?
Or realize you could be back where you started and so
You have to pull yourself together again and set off, faster,
In a different direction but where the walls still look the same,
Hoping to make it out before it gets too dark to see.


Trees, it is your own strangeness . . .

—Ted Hughes, “Trees”

One of the twin maples that rooted over a century ago in our stone wall,
“line tree,” the locals call them, is down. It was always there for me,
cows and horses, birds too, but in its fall took with it part of the wall
and the top strand of barbed wire. The horses are nowhere to be seen
and the cows don’t seem to notice. There are other shade trees, even
the remaining twin, and, if they wanted they could make like Bailey,
the adventurous heifer who followed the deer over the wall and into
our woods. But no. As dusk falls to the music of metal ear-tags, they follow
their leader at a fair clip back down to the barn. That tree had been leaning
too far out for years, its main branch twice as thick as a man’s waist,
the inside rotted out to duff for my garden, just waiting for a storm
big enough to shake the roots in the shallow soil. And now I’m looking
at it from different angles from either side of the wall, even walking on it,
trying to put things in perspective, take it all in. Parts are still green, and
at the top gooseberry bushes are growing in a crotch. Parts are dust, parts
the planks of a sailing ship with scars like the suckers of a giant squid.
There’s so much going on, it’s bigger than just “tree,” or me, and yet it’s
not quite “here” nor “there,” it’s somehow absent or elsewhere. How to get it
straight? How to ask the right questions so it doesn’t all come out as if it has
no mind to call its own, as if there are no other minds, as if it’s all my fault?

swannBrian Swann is the author of several collections of poems, most recently  In Late Lightpublished by Johns HopkinsHe is the author of Autumn Road, winner of The Ohio State University Press/ The Journal Award, and Snow House, winner of the Lena-Miles Wever Todd Prize.

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Malaysia Airlines Flight 370: Why Can’t They Find Any Floating Debris?

Guest post by George Bibel

Air France Flight 447, which was lost in the Atlantic Ocean on June 1, 2009, gives us some insight into why it has been so difficult to recover debris from Malaysia Airlines Flight 370.

In 2009, investigators were unable to find much debris from Flight 447, and many of the pieces that they did find were small. Only 3% (about 1,000 pieces—mostly chunks of insulation and honeycomb construction) of the plane was discovered floating on the surface of the water. The twenty-five foot long composite vertical stabilizer was the biggest floater. (A Boeing 777 like the Malaysian Airlines plane also has composite tail sections.) The biggest piece of fuselage, found on the ocean floor, was only twenty-three feet long.

Debris was also hard in part to find because it spread so quickly. Seventeen days after the crash, the debris and bodies from Flight 447 had drifted 100 miles. On day twenty-five, the debris scatter spanned 200 miles. In addition, depending on water temperature, a body will float for perhaps two to three weeks. Only fifty bodies were recovered back in 2009. At this point, Flight 370 has been missing for more than a month.

Flight 447 completely fragmented on impact. (A belly flop with a vertical sink rate of just 30 mph will severely fragment the plane.) Pieces that float can be torn out as the plane breaks up entering the water.

On the other extreme, a plane going down in the water under pilot control may still break up, which is not good; but the emergency slides double as rafts with radio beacons. In 1996, Ethiopian Airlines Flight 961 was hijacked, ran out of fuel, and went down in the Indian Ocean. The hijackers actually fought the pilot for control of the airplane during the water landing. One hundred and twenty-five out of one hundred and seventy-five passengers died. Most likely more would have lived if the pilot had had full control. If Flight 370 had crashed in this manner, we most likely would have found survivors weeks ago or picked up a signal from the raft beacons.

Finding the black boxes may not be the end of the mysterious story of Flight 370. According to one experienced Airbus/Boeing pilot (the coauthor of my next book), black boxes can be shut off with circuit breakers in most aircraft. In many situations, pilots are required to remove power from the cockpit voice recorder by using the circuit breaker after an incident or accident to preserve the data. And most cockpit voice recorders only record the last two hours, raising the possibility that evidence of a struggle in the cockpit earlier in the flight may have been overwritten.

bibefpoGeorge Bibel, a former NASA summer faculty fellow, is the author of Beyond the Black Box: The Forensics of Airplane Crashes, published by Johns Hopkins. He is a professor of mechanical engineering at the School of Engineering and Mines, University of North Dakota. He recently completed the Air Line Pilots Association advanced accident investigation course.

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Filed under General Science, Physics

Tackling NCDs Effectively Will Require More Health Workers

In honor of World Health Worker Week, we present an excerpt from an article  by Jeffrey L. Sturchio, Louis Galambos and Tina Flores which originally appeared in the Huffington Post.

Imagine having a stroke in a place where the nearest health facility is a two-hour walk away. And should you manage to find your way there, a trained provider isn’t available to assist you. Consider what would happen if the pharmacy ran out of the insulin you needed to manage your diabetes — and all of the other pharmacies within 50 miles of your home were also out of supplies. This would be unusual for those of us who live in the U.S. or Europe, but it is all too often a reality for those in the developing world, where the burden of noncommunicable diseases (NCDs) — cancers, cardiovascular disease, chronic lung disease and diabetes — is the greatest. Health workers are crucial to preventing and treating chronic disease. In recognition of World Health Worker Week, we call on everyone to support efforts to strengthen the human resource capacity needed to tackle chronic disease effectively and efficiently around the globe. Access to well-trained health workers when you need them should not be an accident of geography.

To read more from this article, click here.

galambosLouis Galambos is a professor of history at Johns Hopkins University and co-director of the Institute for Applied Economics, Global Health, and the Study of Business Enterprise. Jeffrey L. Sturchio is senior partner at Rabin Martin, a visiting scholar at the Johns Hopkins Institute for Applied Economics, Global Health, and the Study of Business Enterprise, and former president and CEO of the Global Health Council. Galambos and Sturchio are co-authors of Noncommunicable Diseases in the Developing World: Addressing Gaps in Global Policy and Research

Tina Flores, MS is a Director at Rabin Martin. She has more than a dozen years of experience in global health communications, policy, research and stakeholder engagement, working with NGOs, donors, multilateral organizations and the private sector. 




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Spring Returns to Washington (Really!)

Guest post by Howard Youth

April is a month when there’s no denying winter’s retreat. Even if the thermometer dips below freezing, it rarely stays there for long. Days stretch longer, too. For local plants and animals and the wildlife enthusiasts who observe them, it’s a very busy time.

Washington, D.C. is a capital city not only in the geopolitical sense, but also in a much more animated way. Its location, chosen by George Washington as the best place for a seat of government and commercial hub, also serves the naturalist very well. Washington hosts a staggering array of living creatures thanks to this happy combination of factors: it sits between north and south, at the confluence of two rivers, and along the fall line where piedmont meets coastal plain. Grab a backpack, a pair of binoculars, and a handy field guide (may I recommend my book?), and you will see what I mean. Let’s start with some famous flowering trees.

Youth-cherry-treeMost tourists hope to visit Washington, D.C. in spring. It’s always a gamble planning ahead and trying to be in town when the cherry blossom trees bloom. Here are some insider tips for cherry blossom watching this time of year. First, keep an eye on the National Park Service web page, where you can find updates on predicted bloom dates. Of particular interest is the predicted date for peak bloom, when 70 percent of the Yoshino cherry tree blossoms (pictured above) are open. Top spots for viewing include the Tidal Basin and the Washington Monument. But you also want to visit East Potomac Park, where you find not only the Yoshinos but also the later-blooming Kwanzan and other ornamental cherry varieties. All of these locations are detailed in the Field Guide to the Natural World of Washington, D.C. Following the ferocious winter, this year, the cherry tree experts predict the Yoshinos’ peak bloom will fall between April 8 and 12. Last year’s peak hit within this window, on April 9. The year before was an early March 20.

But when it comes to wildlife—and I’m not talking the bar scene here—Washington, D.C. is so much more than Yoshino blooms. Below are just a few highlights. All locations mentioned here are detailed in the field guide, including visiting tips and key wildlife-watching locations, as well as identification tips.

As you walk around the capital city, watch for these sure signs of spring:

  • Millions of tulips and daffodils blooming in various parks, including along the George Washington Memorial Parkway (Lady Bird Johnson Park in particular) and at the National Arboretum, Dumbarton Oaks, the National Zoo, and many other places.
  • Walk the C&O Canal tow path and keep your eyes open and your ears ready for abundant bird song. Early this month, the adjacent Potomac River provides a corridor for migrating waterfowl and hawks. After the third week of April, neotropical migrants arrive, stake claim to territories, and begin building their nests. These birds include Baltimore and orchard orioles, warbling vireos, yellow-billed cuckoos, great crested flycatchers, and scarlet tanagers. Barn, tree, and northern rough-winged swallows arrive shortly before these species.
  • For other creatures, the business of raising young is well underway. During April, many birds fledge their young, including five woodpecker species, American robins, blue jays, European starlings, Carolina chickadees, and common grackles. Young eastern gray squirrels frisk about. Rare sights in winter, eastern chipmunks and woodchucks (or groundhogs) become familiar sights again in Rock Creek Park, Fort Dupont Park, and other green spaces.
  • Temperature also plays a role. Temperatures above 60 degrees mean dragonflies will be active and bats will be wheeling around at dusk. Above, say, 50 degrees, you may hear tiny frogs called spring peepers “beeping” in low, wet areas, or hear the long trill of breeding American toads. Warm, sunny days draw out the local reptiles, including eastern painted turtles, common water snakes, and striped lizards called five-lined skinks.
  • April also heralds the widespread return of insects. Eastern tent caterpillars’ gauzy nests appear in the crotches of cherry and other trees. Nesting and migrating birds such as cuckoos and orioles feast on this easy protein source, while tiny blue-gray gnatcatchers gather some of the caterpillar nest silk for their own cup nests.
  • Spring ephemeral wildflowers accent floodplain forests this month. These include mayapple, Virginia bluebells, Dutchman’s breeches, and spring beauty.

But April is just a great head start for anyone interested in Washington, D.C.’s varied wildlife. At any season, there is much to see here. At the National Arboretum, for example, you will find something in bloom most months. Even in the dead of winter, sparrows, woodpeckers, hawks, and ducks liven up the landscape.

For those who care to look, every day in Washington, D.C. is a celebration of nature. It’s easy to escape the grind by retreating to the city’s many parks. Any naturalist knows that, when it comes to wildlife, Washington is truly a city that never sleeps.

youthHoward Youth is the author of Field Guide to the Natural World of Washington, D.C.  He is a freelance natural history writer and former associate editor and communications manager for the Friends of the National Zoo. His work has been published in Audubon magazine, National Wildlife, and the Washington Post.  The book’s illustrator, Mark A. Klingler, is a natural history artist in residence at Carnegie Museum of Natural History and illustrator of Field Guide to the Natural World of New York City, also published by Johns Hopkins. The book’s photographer, Robert E. Mumford, Jr., is a wildlife photographer whose work has appeared in Birder’s World, Smithsonian Zoogoer (the National Zoo’s magazine), and the New York Times.


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Filed under Animals, Botany, Conservation, D.C., For Everyone, Regional-Chesapeake Bay, Travel, Washington, Wild Thing