Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.
Could ‘Aid-In-Dying’ Stem Tide Of Senior Suicide?
“Lethal Plans: When Seniors Turn To Suicide In Long-Term Care” (April 9), by Melissa Bailey and JoNel Aleccia, was a significant, interesting, thoughtful article with wonderful stories and solid information. However, the emphasis seems to be on the role of caregivers and various involved institutions to create “safer” environments to foster prevention of elder suicides through better assessment, better trained and more empathetic caregivers, and stronger monitoring and/or oversight.
To me, assessment is the vital piece of the puzzle. If the suicide drive is triggered by depression or other mental health issue, then treatment, well-trained personnel, monitoring, etc. are all on point, with the hope that the suicide ideation will subside as life improves.
However, if loving, thoughtful and professional interactions with the elder reveal that physical or emotional suffering has become unbearable subsequent to a serious, life-threatening illness, the issues involved are very different. They should now be addressed in a patient-centric manner in keeping with the underlying principle of self-determination.
In the article, these issues are only vaguely alluded to, as if medical aid-in-dying is an insubstantial fad or a “rare” policy exception. On the contrary, almost 20% of the U.S. population has legal access to aid-in-dying now that New Jersey’s new aid-in-dying law will take effect Aug. 1.
I wonder about the differences in elder suicide rates in Oregon and Washington, where medical aid-in-dying has been legal for decades. And I wonder if candid, loving discussions about advance care planning and sharing among loved ones about the value of longevity vs. quality of life, etc. are part of the solution. At least it would keep suicide survivors from unending questions, recriminations and flat-out guilt that may be undeserved.
So, my challenge to the incredibly capable and terrific authors is to try and tie these threads together and make the focus about informed decision-making, advance care planning, policies that maximize options (including medical aid-in-dying) and the inevitability of death for the elderly. We all die. Thanks for caring so much.
— Barak Wolff, NM End of Life Options Coalition, Santa Fe, N.M.
Elaborating on her tweet, reader Sharon Moon told KHN: “This is going to become more and more pressing as baby boomers age. I was in risk management in hospitals. In my view, hospitals err on the side of not reporting things. There is a huge culture of retaliation and seeking to sweep problems under the rug. … I can only imagine the way it is in nursing homes that are largely for-profit and without as many M.D.’s to speak out for patients.”

Who can blame them? We have lost our humanity. A nursing home chain owner (4 profit and private) hosted Trump’s CA fundraiser. We need to turn away from money and towards community.
— UnChatUnChat (@CriUnChatUnChat) April 10, 2019

— Sharon Moon, Yardley Borough, Pa.
Is There A ‘Dr.’ In The House Style?
Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care” was an interesting and informative piece on a topic that deserves more public exposure. Thank you for writing it. But would it be possible for KHN to change its style and use the “Dr.” honorific when referring to psychologists? There are many people who describe themselves as psychologists without having a doctorate. And there are other mental health practitioners who are not psychologists at all — social workers and counselors, for example — who are frequently referred to in news accounts as “therapists,” just as a doctoral-level psychologist might be. You may not be aware that psychologists must complete seven years of education, plus post-doctoral work, and that practitioners must go through state licensing. The level of training is on par with doctors of dental surgery, M.D.’s, doctors of optometry, doctors of osteopathic medicine, doctors of podiatric medicine and doctors of veterinary medicine — all of whom are routinely accorded the “Dr.” honorific.
— Kim I. Mills, American Psychological Association, Washington, D.C.
I appreciated Melissa Bailey and JoNel Aleccia’s piece on long-term care suicide. But unclear why you refer to physicians as “Dr.” and not psychologists? Is that KHN editorial policy? Perpetuates stigma.
— Benjamin A. Bensadon, Ed.M., Ph.D., associate professor, University of Florida College of Medicine, Gainesville, Fla.
[Editor’s note: KHN follows Associated Press style for titles and honorifics. Its guideline on medical doctors — with our blanket apologies to Ph.D.’s — reads: “Use Dr. in first reference as a formal title before the name of an individual who holds a doctor of dental surgery, doctor of medicine, doctor of optometry, doctor of osteopathic medicine, doctor of podiatric medicine or doctor of veterinary medicine. … Do not use Dr. before the names of individuals who hold other types of doctoral degrees.”]
After Snakebite, Swift Action (And Taylor Swift) — But Skip Tourniquet
I am the director of The Rattlesnake Conservancy. We are thrilled that you are covering snakebites and educating people without fear-mongering (“Bill Of The Month: Summer Bummer: A Young Camper’s $142,938 Snakebite,” April 30). However, I am concerned that in the radio report on NPR your team mentioned the young lady used a tourniquet and did not mention how dangerous that can be. Many snakebite experts agree that using a tourniquet is dangerous, leading to potentially life-threatening consequences when the tourniquet is removed. Absent loss of life, it also leads to venom accumulation in the limb and significant tissue damage. The best course of action is immobilizing the affected limb and emergency care as soon as possible. No snakebite kits, tourniquets or other devices will help. The only effective treatment for snakebite is antivenom.
The Facebook group “National Snakebite Support” is a crucial tool for anyone who may have been envenomated. The group is staffed by the United States’ top venom specialists and snakebite medical doctors. Their team quickly responds to patients and will communicate with hospital staff on behalf of a patient as needed.
That being said, remember that venom has saved more lives than it has taken. Many medications, including several for blood pressure, arterial clotting and experimental medications, are developed from venomous snakes. For more information, check out our website.
— Anthony Daly-Crews, Buckeye, Ariz.
A hunter weighs in with advice on Twitter:

I’m horribly sad for that family’s financial burden. That’s the biggest reason I wear knee high snake boots…not scared of dying…I’m scared of the bill!!!!
— Bowhunter Metalhead (@BowHunt13773425) May 1, 2019

— Mark Frye, Ash, N.C.
Re: your 9-year-old girl snakebite story: Where was your question about why the girl was wearing open-toed sandals in the woods? Why do you not cover the personal responsibility angle: What did the girl learn? Will she be wearing more protective gear on her return visit this summer?
— Dick Crawford, Anaheim, Calif.
Nothing Like A Good Blood Boiling With My Morning Coffee
I just wanted to convey to the editors of KHN and NPR’s Shots that the “Bill of the Month” series is amazing and I appreciate your work. Normally something I read that gets my blood boiling this easily in the morning is not something I would seek out. However, I appreciate the intent of these articles to call out the ridiculousness of health care charges. What is even more infuriating is the majority of these articles seem to cover individuals who have some sort of health insurance. The reader can only infer what someone without any sort of health coverage would be dealing with!
— Mike Morse, Grand Junction, Colo.

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Further Steps To Guard Against ‘Shameful’ Amputations
Thank you for drawing much-needed attention to disparities in unnecessary limb amputations for communities of color (“Diabetic Amputations A ‘Shameful Metric’ Of Inadequate Care,” May 1). While I applaud your article’s focus on diabetes, understanding related diseases like peripheral artery disease (PAD) is just as important.
As a limb salvage specialist in the Mississippi Delta, I know firsthand that African American patients with diabetes are over three times more likely to have their limbs surgically removed — with even higher rates in Mississippi. Sadly, a majority of the estimated 200,000 annual non-traumatic amputations —many stemming from PAD, a complication of diabetes –– can be avoided with the proper care.
Tragically, even though PAD is as serious as cancer, more than 90% of the amputees I have met have never had a diagnostic test for PAD or an appropriate vascular evaluation to salvage their limbs. Most have never even heard of PAD until it is too late.
To stop these troubling trends in my community, I created a team to aggressively screen, diagnose and treat each one of our 10,000 patients early and often. With no institutional or outside financial support, our practice was able to decrease PAD-related amputation rates in the region by 87.5%.
More must be done on the federal level to address America’s “amputation lottery.” The United States Preventive Services Task Force (USPSTF), for example, should change its recommendation for screening at-risk patients including racial and ethnic minorities and low socioeconomic populations who have a disproportionately higher prevalence of PAD and amputation rates. The current recommendation makes the USPSTF complicit in perpetuating current PAD-related amputation disparities in treatment and outcomes.
There also needs to be broad adoption of non-amputation treatment measures such as revascularization in all algorithms for wounds to heal properly before amputation is ever needed. Finally, policymakers should advance a comprehensive strategy that combines increased public awareness, robust screening and better access to multidisciplinary care for at-risk populations. Together, these steps could go far in reducing limb loss, especially among minority communities.
— Dr. Foluso Fakorede, co-chair of the PAD Initiative for the Association of Black Cardiologists and CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Miss.

This hits close to home: my grandfather, like thousands of Black and Latinx Californians, suffered a lower leg amputation due to lack of access to quality health care and diabetes. Diabetes is a manageable condition and does not *have* to result in amputation. #HealthDisparities https://t.co/miDR4LBfIz
— Jazzmin Williams (@jazzminciara) May 1, 2019

— Jazzmin Williams, San Francisco
I am 69, Caucasian and was diagnosed with Type 1 diabetes 57 years ago. Both of my legs were amputated above the knee in 2014. My overall health has deteriorated since about 2000: heart disease, heart attack, quad bypass, pacemaker, peripheral circulatory disease. Eyes and kidneys are good.
Types 1 and 2 are vastly different, and while the ultimate goal is the same — normalizing blood sugar — Type 1 must be totally controlled with food, injections and exercise. A change in any one changes the others, often drastically. I am a retired engineer and know how to control my diabetes well, but life is tough. I cannot leave home without wheelchair-access transportation. I eat one meal a day, a casserole, of sorts, of beaten eggs, green beans and a small can of chicken breast. Every day.
My injection sites are badly worn, from 20 years of porcine insulin, and I must choose sites I formerly avoided, to get consistent uptake. One must roll the dice with every injection, particularly the fast insulins. Knowledge and extreme discipline are the keys to longevity.
— Mike Kemp, McComb, Miss.

A cousin I grew up with had her leg amputated last summer. It forced me to take better care of myself, but the stats & reasons for this surgery make me sad
— You Are Enough (@KeirstenBrager) April 26, 2019

— Keirsten Brager, Houston
Models Of Superbug Warfare
Reading “How To Fight ‘Scary’ Superbugs? Cooperation — And A Special Soap” (April 12), I wondered: What about other nations? How are they dealing with MRSA and the like? I’ve read that northern European nations and the Department of Veterans Affairs have made excellent progress in decreasing MRSA, or methicillin-resistant Staphylococcus aureus, infections and death rates by screening, isolation and disinfection, while most U.S. health care facilities have not. What is it that other nations (and the VA) are doing to exercise control? Seems they’ve been a lot less freehanded with handing out antibiotics and using antibiotics in low doses in stock animals (chickens, steers in feedlots, etc.). Let’s hear how the rest of the world’s health care systems are dealing with the problem — the U.S. might learn something. Just as we’d do well to adopt a system for providing health care from at least one of 10 other nations, who get better results with less expenditure/capital than the U.S. does.
— Susan Hogg, Newport, Ore.

Clearly dealing with the most dangerous pathogens, but I wonder if the chlorhexidine also kills protective, beneficial bacteria and introduces new risks to the patients and caregivers.
— Gary Lindsay (@GaryLindsay27) April 3, 2019

— Gary Lindsay, Bellingham, Wash.

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