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Dr. Barak Gaster: I’m a primary care doctor at the University of Washington and a professor of medicine at the University of Washington School of Medicine. For 20 years, I’ve had a job that includes a mix of seeing patients and doing research and curriculum development on the hardest issues facing primary care doctors. Over the years, I’ve written and worked on topics such as the complexity of talking to men about prostate cancer screening; how to treat chronic pain safely in a primary care setting; and how to talk to patients about the pros and cons and evidence behind herbal medicines.

It was about four years ago that I realized that the hardest issue facing primary care doctors, and really society in general, is dementia. The number of people who are living with dementia is increasing quickly. We as primary care doctors are really struggling with how best to identify it in its early stages and how to help patients and families navigate through the stages of the disease. So, four years ago, I started building a curriculum for primary care doctors addressing how to identify dementia and help patients and families navigate through it. As part of doing that, I really wanted to focus on the process of helping patients and families with advance care planning, specifically as it relates to dementia.

I started figuring out what kind of tools would be helpful for people in expressing what their wishes are if they were to have worsening dementia. I’ve been working on that with other colleagues here at the University of Washington, in fields like geriatrics and palliative care and neurology, to come up with advance directive for dementia. We published our work in the Journal of the American Medical Association about a year ago. It was written about in the New York Times in January, and since then more than 100,000 people have downloaded the form from the website where it’s available for free for anyone that would like to take a look at it.

Dr. Gaster: It was almost exactly a year ago, right when the JAMA article came out in November. It truly didn’t have that much traffic until January, when the article came out in the New York Times, then there was a giant amount of interest. gas yojana We had a really nice interview about the advance directive for dementia on NPR soon after that. Since then, it’s been a grassroots phenomenon. Between 500 and 1,000 people are accessing it each week all over the country.

Dr. Gaster: My main job is to be a primary care doctor, and I think really hard about the issues that are most difficult for me as I go through my day. I talk to my colleagues about what they find to be the most difficult issues. I’m very involved with medical education at the University of Washington School of Medicine, so I supervise residents as they go through their continuity clinic during their three years of internal medicine training. In doing that, I also see which issues they end up struggling with the most. Those are the issues that are the most interesting to me and the ones I want to figure out how to approach in an efficient and family-centered way.

Dr. Gaster: Yes, there are two things that are greatly contributing to that trend. gas vs diesel prices One is that people are living longer than they have before. We’re doing a better job of treating heart attacks and cancer, so people are living into their 80s and 90s with a much higher frequency than before. There was also a demographic phenomenon that happened between 1945 and 1965 called the Baby Boom, where the number of live births in the United States had a huge spike. The result is that there’s a big population bubble today. The older baby boomers are now in their late 60s and early 70s, which is the age at which people start to become at risk for dementia. The fact that more baby boomers will live into their 80s and 90s than any generation before them, and the fact that there are a lot more of them, result in estimates that the number of people living with dementia in the United States is going to double and even triple in the coming years.

Dr. Gaster: As I set out in thinking about this problem, I looked for other examples of dementia living wills. I didn’t find much out there, and that’s partly because it’s a tricky issue to try and anticipate and give guidance for because it’s a complex disease that lasts for a very long time and goes through many different stages that are pretty different from each other. It’s not like you can say, “If I have dementia, I want this,” or “If I don’t have dementia, I want that,” because it’s not black and white, it’s a very gradual process of losing your cognitive function.

What’s different about dementia is not only that it is very slowly progressive, so it changes very gradually, but also that for a very large portion of that time people have lost the ability to guide their own care. For other diseases that progress slowly, like heart disease, up until the very end people are perfectly able to make decisions about their care. So having a specific directive for all of those conditions doesn’t make much sense. Dementia is different because very early in the process people become less and less able to make medical decisions about their care. So that’s where you really need an advanced directive to express your wishes and give your loved ones something to reference to help guide them in the decisions that are often really hard for people to make.

Dr. Gaster: The way that we ended up structuring it was by thinking about dementia in three broad stages: a mild, moderate and severe stage. electricity outage san antonio For each of the three stages, we present a brief description of the milestones that mark that stage for most people. Under those three descriptions, we give people four options to choose from in terms of what they would want the goal of their medical care to be. It allows people to express how they want the goals of their medical care to shift as the disease progresses.

Dr. Gaster: When I was first developing the form, I thought the most important time for people to fill it out would be at that very earliest stage when there was detectable signs of dementia. At that point, it would be clear that someone would need a directive like this and that would be a really important window of time to help them fill it out while they were still able. But I found that only a small number of people who I’d diagnosed with mild cognitive impairment filled out the form. The majority of the time people seemed like they were grateful and promised that they would take it home and think about it, yet they they almost never brought the form back.

Then, instead of giving it to people I was diagnosing with early stage memory loss, I just started giving it to everyone. I gave it to all of my patients who were there for their regular check-ups, starting at age 65 or 70. Remarkably, I found that 70 or 80 percent of people without cognitive impairment started returning the forms to me. That’s when my thinking shifted. I began thinking the best time for somebody to fill a form like this out is when they hit the age when they are at significant risk of developing dementia — around 65 or 70 –before they develop any signs of cognitive impairment. It’s more difficult for people with mild cognitive impairment to fill out the form, for reasons I will go into.

“Sadly, times have changed and there’s basically one way most kids seem to die now,” states the introduction to MAD’s graphic tale. The Gorey update “out-macabres” the original as it reports on the deaths of “Eve who’s idealistic … Greg who was caught unawares … Hiro who needs more than prayers … Julie who’s too young to vote … and Stephen who’s planning for prom,” along with 21 other classmates doomed to die by a bullet shot on their school grounds.

The MAD Magazine warning comes at a time when the unsettling increase in school shooting deaths seems to be rallying support for stricter gun laws. Those in favor of what has been described as sensible change spiked in polls after the 17 fatalities suffered at the Margory Stoneham Douglas High School in South Florida earlier this year. Roughly 2 in 3 Americans now say gun control laws should be made more strict, compared with just 1 in 4 who oppose stricter gun laws. According to Marie Claire magazine, 33 pro-gun control lawmakers will support common-sense gun reform in 2019. electricity worksheets grade 9 A time when real life takes a satirical statement made by MAD Magazine seriously may be on the horizon.

“Poems of Mourning” is a volume from the Everyman’s Library Pocket Poets Series, which, in turn, is part and parcel of Everyman’s Library, a reprint series that publishes new and beautiful editions of literary classics, mostly from from the western canon. Founded in the United Kingdom in 1906 by Joseph Dent, a master bookbinder turned publisher, the Everyman’s Library seeks to offer classics that “appeal to every kind of reader.” John Gross said of Everyman’s Library, “Other reprint publishers merely published reprints; Everyman’s Library was an institution, a benign presence, a crusade, and act of faith.”

The Everyman’s Library Pocket Poets Series consists of elegantly bound poetry anthologies. Each volume, with its full-cloth sewn binding and silk ribbon marker, feels like a special invitation into a sacred world of words. There are more than 80 titles in print, including one dedicated to poems that deal with grief and loss, and death and dying. The volume is called “Poems of Mourning,” and it is edited by Peter Washington, who is the General Editor of Everyman’s Library and editor of a number of the anthologies.

“Poems of Mourning” includes poems that touch on the various stages of the grieving process. gas near me open now There are poems that grapple with despair over loss, with anger over loss, and with acceptance. There are poems that approach the subject with humor, others that approach it with a tone of melancholy. What they have in common is their attempt to distill the overwhelming experience of mourning into lines that resonate, to wrestle grief into sentences and stanzas that might speak to the reality of loss.

While you may not be familiar with The Pogues (unless you’re a child of the 70s with an appreciation for Irish folk music with a punk sensibility), the mark they left on Christmas is undeniable. They created one of the greatest Christmas ballads of all time by blending strong roots in tradition with the lament of a generation left cold by the Thatcher years and marginalized in their own economies. The result is something that not only endures, but has meaning for many who find themselves feeling something less than Christmas cheer.

To understand “Fairytale of New York,” you need to know just a little about Ireland in the 80s. Northern Ireland — a different state from the Republic of Ireland — had long been engaged in a struggle for independence from the British, most notably in the form of the Irish Republican Army. And it wasn’t just the people of Northern Ireland who were strongly Republican; this is a sentiment deeply rooted in the Irish identity, and the spirit of rebellion was alive and well across the island. The Pogues

Enter Shane MacGowan and The Pogues. The Pogues, though most band members were English, made quite a stir in the London scene with their raucous brand of folk music, much of it Irish rebel music. They were both loved and hated, especially due to MacGowan’s unrepentant rebel soul and his brash, upfront style. MacGowan was also a very unattractive man, if I can say that, and seemed to perfectly embody the rallying cry of the forgotten Irish youth. He also liked to drink quite a bit.