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Most people in health care understand and accept the need for clinical hierarchies. The problem is that we aren't usually prepared for them; nor are we given protocols for resolving the inevitable tensions that arise over appropriate care. Doctors and nurses are trained differently, and our sense of priorities can conflict. When that happens, the lack of an established, neutral way of resolving such clashes works to everyone's detriment. This isn't about hurt feelings or bruised egos. Modern health care is complex, highly technical and dangerous, and the lack of flexible, dynamic protocols to facilitate communication along the medical hierarchy can be deadly. Indeed, preventable medical errors kill 100,000 patients a year, or a million people a decade, wrote Rosemary Gordon and Janardan Prasad Singh in their book "Wall of Silence."

Until very recently, technology had a clear, if boring, purpose: by taking care of the Little Things, it enabled us, its human masters, to focus on the Big Things. "Unless there are slaves to do the ugly, horrible, uninteresting work, culture and contemplation become almost impossible," proclaimed that noted connoisseur of contemplation Oscar Wilde. Fortunately, he added a charming clarification: "Human slavery is wrong, insecure and demoralizing. On mechanical slavery, on the slavery of the machine, the future of the world depends." ...Alas, most designers, following Wilde, think of technologies as nothing more than mechanical slaves that must maximize efficiency. But some are realizing that technologies don't have to be just trivial problem-solvers: they can also be subversive troublemakers, making us question our habits and received ideas. Recently, designers in Germany built devices - "transformational products," they call them - that engage users in "conversations without words." My favorite is a caterpillar-shaped extension cord. If any of the devices plugged into it are left in standby mode, the "caterpillar" starts twisting as if it were in pain. Does it do what normal extension cords do? Yes. But it also awakens users to the fact that the cord is simply the endpoint of a complex socio-technical system with its own politics and ethics. Before, designers have tried to conceal that system. In the future, designers will be obliged to make it visible. While devices-as-problem-solvers seek to avoid friction, devices-as-troublemakers seek to create an "aesthetic of friction" that engages users in new ways. Will such extra seconds of thought - nay, contemplation - slow down civilization? They well might. But who said that stopping to catch a breath on our way to the abyss is not a sensible strategy?

"Do you have a solve for this problem?" "Let's all focus on the build." "That's the take-away from today's seminar." Or, to quote a song that was recently a No. 1 hit in Britain, "Would you let me see beneath your beautiful?" If you find these sentences annoying, you are not alone. Each contains an example of nominalization.... I don't actually care for "Do you have a solve?" Still, it is simplistic to have a blanket policy of avoiding and condemning nominalizations. Even when critics couch their antipathy in a language of clinical reasonableness, they are expressing an aesthetic judgment. Aesthetics will always play a part in the decisions we make about how to express ourselves - and in our assessment of other people's expression - but sometimes we need to do things that are aesthetically unpleasant in order to achieve other effects, be they polemical or diplomatic.

Pro's & con's on assisted suicide, & adequate support for patients & caregivers at end-of-life - initiated by letter by Janice Lynch Schuster, at Ctr for Elder Care & Advanced Illness, Altarum Institute

... not quality of pt care

...like SPV: independent living to ALF to SNF care.

The Affordable Care Act's updated versions of HMOs are based on flawed assumptions about doctor and patient behavior.

Most prestitious hospitals receive billions to train residents, few of whom go into primary care, where society needs them most.

>'With unrealistic expectations of our ability to prolong life, with death as an unfamiliar and unnatural event, and without a realistic, tactile sense of how much a worn-out elderly patient is suffering, it's easy for patients and families to keep insisting on more tests, more medications, more procedures. >Doing something often feels better than doing nothing. Inaction feeds the sense of guilt-ridden ineptness family members already feel as they ask themselves, "Why can't I do more for this person I love so much?" >...At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. We've committed ourselves to relieving suffering, not causing it. A retired nurse once wrote to me: "I am so glad I don't have to hurt old people any more." '

Even when the system works as it's supposed to, and palliative care specialists arrive like the cavalry to provide comfort care, to stop fruitless and painful interventions and to support what patients want, their own colleagues may brand them murderers. It takes strong doctors to stand up to that kind of verbal abuse, to explain that courts and ethics committees have approved care that's intended to reduce suffering, to point out that the patient's own wishes are paramount. Perhaps they have to be stronger than we know. "The culture is changing," Dr. Matlock told me. "But it's not changed yet."

Online support systems for family member's complex medical needs

The North Shore-LIJ Health System, with 16 hospitals and more than 300 outpatient centers in Long Island and New York City, is laying the groundwork to be an insurer, as well as a provider of health care.

ALF usually leads to NH (if survive)

Poor analysis of mis-spent $ at EOL

Startup cost & shortage of palliative MDs.

The researchers found that in areas where end-of-life care costs were normally high, having an advance directive significantly lowered the cost of care. On average, end-of-life care spending was $5,585 less per person in the high-spending regions when someone had an advance directive. > Having an advance directive didn't necessarily limit the initiation of aggressive treatments, but seemed to lead to their earlier withdrawal. Author said this finding was particularly important because some people make the argument that having an advance directive might limit all of the care you receive at the end of your life. But, this finding shows that while treatments are often started, for "patients with an advance directive, there's an earlier recognition of when treatments aren't working and when it's time to go to hospice."

"New York's newest basketball sensation spends most nights on a couch in a one-bedroom apartment on the Lower East Side. The housing choice is understandable once you get to know Jeremy Lin. He is a Harvard graduate playing in the National Basketball Association. He is an Asian-American in a league devoid of them, which makes him doubly anomalous. No team drafted Lin in 2010. Two teams cut him in December, before the Knicks picked him up. His contract, potentially worth nearly $800,000, was not even guaranteed until Tuesday afternoon. So for the past six weeks, Lin, 23, has been sleeping in his brother Josh's living room, waiting for clarity and career security."

26,000 premature deaths/yr in US b/o no health insurance

Actually GOALS for changing medical culture