Practicing 'slow medicine' in elderly patients

I came across an interesting article in the New York Times this week, entitled “For the Very Old, a Dose of ‘Slow Medicine.’” The article was a review of the book, “My Mother, Your Mother: Embracing ‘Slow Medicine,’ the Compassionate Approach to Caring for Your Aging Loved Ones.”

A definition given by the book’s author, Dr. Dennis McCullough is, “Slow Medicine advocates for careful anticipatory ‘attending’ to an elder’s changing needs rather than waiting for crises that force acute medical interventions—an approach that improves the quality of elders’ extended late lives without bankrupting their families financially or emotionally.”

In other words, this is a movement that seeks to reduce the instrumentation and overly technical approach to all medical concerns amongst our older patients, and to proactively anticipate problems rather than solely respond to the crises as they happen (you know they will eventually happen, so why not be prepared?). This book is geared towards family, not health care providers. In addition, I have not read the book, only the clips offered in book reviews and on Amazon, so take these thoughts with a grain of salt. But the book seems to advocate for taking things slowly—don’t call the ambulance for every bump in the road. Don’t try the newest medicine on the market, stick with the tried and true. When you do start a new medication, “start low and go slow,” or in other words, start at a low dose, and make gradual increases in the dose. Always take that opportunity to say “thank you” and “I love you” to your older loved one.

I think this approach is intuitive to many oncologists. We deal in medications that have the very real side effect of life-threatening toxicity, and prior to offering chemotherapy to any patient, we balance the risk:benefit ratio in our heads. It’s just that with the older adult, the risks are usually greater and the benefits, conceivably less. Perhaps you have taken chemotherapy off the table based upon the frailty of your patient, or their expressed desire not to prolong their life. Some oncologists, though, do not take age or frailty into account at all. The old saying is, “If all you have is a hammer, everything looks like a nail” … if all you have is chemotherapy treatment, all cancer looks treatable, I suppose.

I believe families sometimes play into this decision as well—the younger child thinking that you might try “everything” to fight the cancer. I think the right approach is somewhat more nuanced, and requires a detailed discussion about goals of care before chemotherapy is offered). Some elders do warrant a trial of chemotherapy, some do not. Sometimes age is a good barometer of ability to tolerate chemotherapy, frequently it is not. There is also a desperate need for a more scientific or evidence-based approach to this rather than just gestalt … but that’s another blog entry.

I like the concept of being thoughtful with interventions for elders, but I think the prevailing thought among geriatric oncologists is that elders are undertreated, not overtreated, and this may further that disparity.