Thoughts on “Being Mortal”

being mortal

Atul Gawande’s marvelous book “Being Mortal: Medicine and What Matters in the End”, is a must-read for anyone who plans to age in the USA. Dr. Atul Gawande is a surgeon, a professor at Harvard Medical School and the Harvard School of Public Health, a writer for the New York Times, and the author of three bestselling non-fiction books on science and public health. He makes difficult subjects interesting and understandable. You don’t have to be a scientist to understand and enjoy his books.

In “Being Mortal”, Dr. Gawande writes eloquently about the history of how we care for our aging population and the importance of retaining the dignity and freedom to be the “authors of our own lives.” In the end, when all else is said and done, that is what matters.

This book has inspired me. This month, I spoke at the Arizona Geriatric Society’s Fall conference. My topic was “Managing Dysphagia Beyond Acute Care”. Once read this book, I reworked my presentation. I made sure to address the joy of eating, the social aspects of sharing a meal and the cultural significance of food. The medical professionals who attended this conference know the science so I shared with them my thoughts on the art and soul of eating.

“Being Mortal” is a call to action for doctors and other medical professionals to expand our responsibilities beyond trying to “fix” what is wrong and embrace the final years of living. This time period should be about living as fully as possible and having the best possible day (week/month/year); it should not be focused on dying.  As we reach advanced age or fight a terminal illness, much of what happens to our bodies can’t be “fixed”. Yes, we can eat right and exercise but there is nothing we can do to stop time.

For many of us, as we age, our ability to swallow can become impaired. Illnesses like oral cancer and dementia can rob us of more than our vitality; they can steal from us our ability to eat and enjoy food. According to the National Institutes of Health, one in six Americans over the age of 60 is having trouble swallowing. In 2013, over ten million Americans had a swallowing assessment.

In “Being Mortal” Dr. Gawande builds the case that “as our time runs down, we all seek comfort in simple pleasures – companionship, everyday routines, the taste of good food, the warmth of sunlight on our faces”. Not being able to eat and drink like everyone else can interrupt our everyday routines, be isolating and can lead to depression. Food and eating is basic to our survival, but is even more important to our quality of life and our joy of living. How we eat and with whom we eat feeds the spirit.

Caring for someone with swallowing problems is about more than the mechanics of feeding. Doing it right is science combined with art. With the right tools, creativity and information, it may be possible for those with swallowing problems to share and enjoy a meal. Diagnoses and food modifications help to sustain the ability to nourish the body but we should acknowledge that we need to feed the soul, as well.

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Swallowing Problems? What to do about Thanksgiving dinner.

Family eating at the dinner table

Gathering at the holiday table is one way we share our love, show our humanity and honor our cultural traditions. For manyof us, holiday feasts like Thanksgiving and Christmas don’t feel like a holiday without certain well known and loved dishes. Traditional foods and recipes are handed down from one generation to the next, keeping alive our memories and honoring those no longer at the table.

For most of us, feasting with friends and family is basic to our humanity. But when you are having trouble swallowing, the act of eating can be scary, difficult or even dangerous.  Needing to be conscious of every bite you take, how you position your head and thinking through the swallow is no picnic! It can create anxiety, prevent you from being in the moment, taking part in the conversation at the table and enjoying the occasion like everyone else. Those who are recovering from a stroke, are having treatment for cancer or who are living with dementia may already feel isolated.  Not being able to share traditional family meals in a “natural” manner may be frustrating and challenging and can make matters worse.

It is understandable when those with swallowing problems may be tempted to “cheat” during the holidays and eat foods that are not part of their eating plan. Sharing traditional foods with family and friends is how we celebrate! Platters get passed and everyone takes a little bit of this and maybe a whole lot of that. Traditional foods have a special place at the holiday table but if those foods are the wrong texture, they can be a problem for someone who is at risk for aspiration. Aspiration is when a small particle of food or liquid enters the trachea (a.k.a. the airway or windpipe).  Aspiration can cause choking and aspiration pneumonia, both of which can be life-threatening.

Whether your family celebrates a holiday dinner with roast beef, turkey or ham, it is possible for someone with dysphagia to eat almost everything on the dinner table with a few modifications.

If you are on a Mechanical Soft Diet, remember to take small bites of soft, well-cooked foods. Add gravy and sauces to your foods to make them moister and easier to chew and swallow. Dark meat turkey is often more moist and tender so choose thigh meat and cut it into small pieces. Be mindful when eating foods with mixed textures. Avoid foods that aren’t easy to chew like nuts and raw vegetables. Stick with roasted vegetables and stay away from the crudité plate. Have the pumpkin pie instead of the pecan pie.

If you’ve been prescribed a puree diet, you’ll need a make a few additional modifications to many foods to make them the right texture for you.  To puree a single serving or two, you will find that a powerful mini food processor will become an invaluable tool.  Full-size food processors and blenders won’t work because they are too big to efficiently puree one or two portions to the correct texture. You will also need an instant food thickener like ThickenUp Clear® or ThickIt®.

Here is a puree plan for most traditional foods:

Turkey

Roasted Turkey/Beef/Ham/Brisket

  • In a mini food processor, place cooked a 2 – 3 oz. portion of cooked meat and process until finely chopped. Add 2 tablespoons of broth and process again until very finely chopped. Add 1 scoop instant food thickener and puree until smooth. The texture should be as thick as mashed potatoes. For visual appeal, place the meat in the corner of a quart-size zip-top bag and seal. Snip off the corner with the meat, and pipe the puree onto a plate in the approximate shape and size of a serving of meat.

Mashed Potatoes & Gravy

  • No modifications needed, just make sure the potatoes and gravy are lump-free and the potatoes are firm (not soupy).

Stuffing

  • Avoid stuffing. Try slurried dinner rolls (below) which taste a lot like stuffing.

Sweet Potatoes

  • Mash with lots of butter.

Green Bean Casserole

  • No mushroom soup allowed. Instead, puree a portion of well-cooked green beans and fried onions in a mini food processor with a small amount of cooking liquid. Add 1 scoop of Instant Food Thickener (I like ThickenUp Clear) and blend until smooth. You are looking for a texture like smooth mashed potatoes.

Dinner rolls

  • Use only soft dinner rolls. NO SEEDS OR WHOLE GRAINS! Make a slurry with ¼ cup of chicken broth and ½ scoop of Instant Food Thickener (ThickenUp Clear) and mix until it thickens. Pull apart the roll and cover with the slurry. Set aside for about ten minutes, until the roll has absorbed the slurry. Reheat as needed.

Cranberry Sauce

  • Canned smooth, jellied sauce is okay.

Pumpkin Pie

  • Filling only. No crust.

Apple Pie

  • Puree the filling in a mini food processor. No crust.

If you crave apple pie a la mode, check-out the archived recipe on this blog.

With a few modifications, you or someone you love can safely enjoy a holiday feast!


Braised Red Cabbage and Family Ties

With the change of weather and cooler temperatures, I’ve been craving braised red cabbage, something I don’t normally eat. But I don’t want just cabbage. I want potato pancakes made from shredded potatoes, or “rosti” which are Swiss hash browns and meat. Gotta’ have some sort of pork seasoned simply with salt and pepper; the darker the meat, the better.

I don’t normally eat this way. All summer, I live on salads and vegetable-based meals combined with some grilled meats and maybe some grilled fish. But for the last couple of weeks, I’ve wanted cabbage, potatoes and pork; German comfort food.

I think my craving may just have something to do with the genealogy my sister, Renda, has been doing.  Recently, she traced the maternal side of our family back to our great-great-great-great grandmother Catharine Brodbeck, who emigrated from Baden, which is in southwestern Germany, through the city of Breman, to the US in 1854. Catharine traveled with her nine (!) children on a small ship, landing in New York on the day after Christmas in 1854. She then traveled to Ohio to join her husband, the father of her children. Catharine had a total of 14 children but the nine she traveled with ranged in ages from seventeen to as young as four years-old.

When I think of the kind of woman great-great-great-great grandma Catherine must have been, I’m in awe. She traveled half way around the globe, without her husband, with nine children in tow. When she climbed aboard that ship, she’d left behind her home and her extended family. Like so many immigrants, she and her children left their homeland to escape war and economic hardship. Baden is on the banks of the Rhine River, an area that has seen struggle and conflict for centuries.

Once aboard that small ship, what was daily life like for Catharine and her children? How she they feed everyone?  What did they eat? I can’t imagine traveling for weeks and weeks with nine hungry, growing children.

And when they arrived in the US, how did the family travel the 540+ miles overland between New York and Ohio?  How long did that trip take? How did she feed everyone then? She and her children made this journey a century before the interstate highway system, with its convenient rest stops and exits for food and restroom breaks. Cars wouldn’t become commonplace for another six decades. What drive, determination and optimism they must have had to have completed just that part of the journey!

So, last night when I made a dinner of braised red cabbage with rosti and grilled country-style pork chops for my family, I thought of her. These foods I’ve been craving are traditionally German. Did Catharine feed her family these foods, as well? Is she why I crave them?  As I looked across the dinner table at my nine year-old son, I thought about Catharine. I could feel her presence so I told my son her story, which is his story, too.

Sharing and eating goes far beyond nourishing the body, it also touches the soul and honors the past. Braised red cabbage = family ties for me.

 Spicy red cabbage stewed with apples

 

Braised Red Cabbage

2 tablespoons butter

1 medium head of red cabbage, quartered, cored and cut into ¼ inch strips

1 tart green apple, skin-on, quartered, cored and cut into ¼ inch slices

¼ cup apple cider vinegar

¼ cup water

3 tablespoons granulated sugar

2 teaspoons salt

¼ teaspoon ground black pepper

¼ teaspoon ground cinnamon

In a heavy large skillet or Dutch oven, melt butter over medium heat.  Add the cabbage and apple and toss until all is coated with butter and begins to melt. Add the vinegar, water, sugar, salt, pepper and cinnamon and mix thoroughly. Reduce the heat to a bare simmer, cover and cook for about one and a half hours, stirring occasionally and adding more water, as needed, to prevent sticking.

This dish is even better the second day!

For a mechanical soft diet: no modifications.

If you are on a puree eating plan:

In a mini food processor, pulse ½ cup braised red cabbage with 2 tablespoons water. Once finely chopped, add ½ teaspoon instant food thickener and process until completely combine. It should have the texture of firm mashed potatoes.

Yield: 6 servings

97 calories. 3 gm fat, 17 gm carbohydrate, 4 gm dietary fiber, 3 gm protein. 800 mg sodium. 44% Vitamin C. 181% Vitamin A.