Adventures in Careland

Fifteen years ago, Gilah Silber became a geriatric physician because she wanted to offer comfort and even joy to people as they made their last passage in life. Dr. Silber trained with a strong purpose to care for the aging and dying individual-in body, yes-but also in mind and spirit. To her dismay, she went on to practice medicine in a place she never expected to go, namely, a wonderland of nursing home facilities, where up was down, and down was up. As her adventures in long-term "careland" have taught her, it is the institutions that are at the center of the universe, not the people they are meant to serve. Billing specialists, insurers, lawyers, regulators, marketing personnel, pharmaceutical representatives, and care plan writers radiate like rays of the sun-while residents and their doctors orbit in the outer darkness. There is little in Dr. Silber's experience to suggest that what is upside-down will soon right itself; not unless more attention is paid to what goes on behind the nursing home façade. Toward that end, she asks us to take a hard look at the absurdities of attempts to "solve" the problems of aging and dying by enforcing a rigid regulatory and corporate structure and a depersonalized, detached, and pseudoscientific approach to long-term care. In her earlier book, Living and Dying in a Long-Term Care Facility: Notes From a Nursing Home Doctor, Dr. Silber gave us gripping accounts of her many patients and she does so again. In this latest book, she delves further to describe the kinds of people who staff nursing homes and identifies six types of care teams: dysfunctional; absent; threatening; passive; nonexistent; and (amazingly) normal. The latter is not necessarily ideal, she writes; normal teams do not suit everyone. She also observes that certain…