Building Unity Farm - Thanksgiving on the Farm

Thanksgiving is a time for family and friends to reflect on the past year, be grateful for the good things that happen every day, and consider the journey we're all on, which is hopefully headed in a positive direction.

On a farm, this day of thanks is very personal.    As with last year, the foods we prepared were either grown at Unity Farm or at a farm within one mile of our dining table.   There was one exception - the cranberries were from a bog on Cape Cod.

We boiled turnips and roasted root vegetables.   We picked mixed lettuce from the hoop house.   We baked pumpkin and apple pies with fruit picked from our orchard. We opened bottles of Unity Farm sparkling hard cider made this Fall in the cider house.  We made stuffing from chestnuts and oyster mushrooms, fresh picked from our mushroom farm.   Next year we'll have shitake to add to the table, but this winter the logs are still in their mushroom growing phase.

The alpaca got an extra helping of alfalfa mixed with molasses.  The dogs enjoyed a few fresh eggs.  The chickens, ducks and guinea fowl got fresh lettuce.

I've described life at Unity Farm as joyful chaos.  There are always chores to do.   There are no vacation days or weekends.   But somehow, I never feel that hauling hay, filling water buckets, turning compost, splitting logs and the constant movement needed to support the plants and animals constitutes work.   We spent the day as a family doing everything needed to support the community living on the farm.   My daughter split ash and black birch logs for the hearth.  I chainsawed fallen trees and branches from yesterday's storm (we had 40 mph winds and 3 inches of rain).  My wife watered our winter produce in the hoop house and planted new vegetables - the hoop house was 80F at midday while the outdoor temperature never rose past 32F.

The family spent the day together doing tasks that benefitted all.

Tomorrow, we have no shopping planned, just tasks that will further help us prepare for the heavy snows that are likely to start in a few weeks.

This was my first Thanksgiving without my father, so we took time at dinner to pay tribute to those not present - my Father, Kathy's mother, and those who we've known in life who are no longer with us.

I hope you have a peaceful day and many things to be thankful for.   Although we all face many challenges, hopefully you still have a sense that the future will be even better than today.

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Pre-Thanksgiving Giving Thanks

by Baxter

Lanterns by Melina Meza

So, it’s one day from the annual gathering of families and friends that we in the USA call Thanksgiving, and it occurs to me that I haven’t yet thanked the staff here at Yoga for Healthy Aging, all of whom do their work for you as a labor of love.

I am so grateful for the staff of YFHA! We have grown in the past two-plus years to an impressive eight people who regularly contribute to the posts that you read each week. In addition to the original crew of Nina, Brad and me, Shari Ser, PT, Timothy McCall, MD and Ram Rao, PhD regularly write posts with unique perspectives that have enriched our offerings greatly. So a big thanks to this trio of insightful and talented yogis and writers!

Bridget Frederick, our copy editor, has been going over our posts regularly with a fine-tooth comb, which those in the biz know is essential for coherent and understandable writing. She also makes it possible for Nina to take occasional time off by doing behind the scenes blog maintenance work. Invaluable! Melina Meza has generously offered to share her beautiful photos with us, and they have started to adorn many of our weekly posts. Other photographers have contributed photographs as well, including Philip Amdal, Joan Webster, and Michele Macartney-Filgate. Thanks, team—you make this adventure of love a Walton’s Family style one!

Maybe as importantly, THANK ALL OF YOU OUT THERE who read us regularly—you are a huge inspiration for the posts you read here each week! You’re now part of the YFHA family, too.

Happy and Healthy Thanksgiving to all our readers!

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Rethinking Certification

As stakeholders in payer, provider, and government communities debate the optimal timing of ICD10, Meaningful Use Stage 2, ACA, and HIPAA Omnibus rule deadlines, it's becoming increasingly clear that many hospitals which attested in 2011 and 2012 will not have their 2014 edition certified software installed, training completed, and workflow re-engineered in time for the Stage 2 attestation deadlines.

Now that we have experience with two stages of Meaningful Use, it's also clear that a three year cycle is needed to ensure safe, high value, well adopted, introduction of new IT functionality.

Part of the problem, as I've discussed previously, is that the certification criteria are overly burdensome and in many circumstances disconnected from the attestation criteria, requiring very prescriptive features that go beyond the intent of Policy Committee and Standards Committee.

How did this happen?  When Meaningful Use Stage 2 regulations were being written, ONC entered a "quiet period" in which smart people wrote regulatory language and certification scripts isolated from the rest of the world to ensure there was no bias introduced.   This was a "waterfall methodology" in which elaborate specifications and a long planning process was followed by an isolated development process resulting in a single huge deliverable with little opportunity to validate the result, pilot the components, or revise/improve the product after the fact.  The flaws in the Stage 2 certification scripts are an artifact of the regulatory process itself.

Healthcare.gov taught us that waterfall approaches are risky.    A better approach would be to create certification scripts using an "agile methodology".   Standards and scripts to test them could be developed outside the regulatory process, with iterative stakeholder feedback, testing of components, and rapid cycle improvement.   The regulatory process could point to the standards which would have accompanying implementation guides and test scripts.   There would be no "quiet period" or isolation in the development of certification scripts.    Such an approach would significantly reduce future certification burdens.

In addition to this, I recommend an even more radical redesign of certification.

We should maintain attestation as a demonstration of performance, but limit certification to rigorous standards adoption and interoperability, not prescriptive functionality.

What do I mean?

The Meaningful Use Workgroup believes decision support should be expanded in the future.   I agree.   Although they are now looking at outcomes that demonstrate the use of decision support, their initial work included recommendations for very prescriptive decision support certification criteria including:

Ability to track CDS triggers
Ability to flag preference-sensitive conditions and provide decision support materials for patients
Check for a maximum dose /weight based calculation
Use of structured SIG standards
Consume external CDS interventions
Use info in systems to support maintenance of lists

In effect, this tells vendors how to enhance clinical decision support features.

Let me use analogy.

Suppose that the government decided USB thumb drives are a good thing.   Not only would they specify a USB 3.0 standard, they would require it is black, rectangular, and weighs 2 ounces.    Such prescriptive requirements would stifle innovation since today's USB drives might be in the shape of a key or even mimic a sushi roll.

When evaluating the success of the US healthcare IT program, Congress tends to focus on interoperability - why are there gaps in DOD/VA data sharing or few seamless transitions of care among inpatient and outpatient facilities?

If certification focused entirely on interoperability, EHRs would be a bit more like USB drives.  They might be big or small, black or red, key shaped or sushi shaped.  However, they'll work with any device you plug them into.

I've spoken with many EHR vendors (to remain unnamed) and all have told me that they created software that will never be used by any clinician but was necessary to check the boxes of certification scripts that make no sense in real world workflows.

If certification required rigorous demonstration of outbound and inbound interoperability with no optionality in the standards (use this standard OR that standard), Congress will be happy, patients will be happy, and vendors will be happy.

Once we come up for air after ICD10, MU2, ACA, and HIPAA, I'll be watching any MU3 planning very closely to ensure we do not again make the same mistakes with certification scripts that are untested or too prescriptive.   Let's all focus on universal adoption of enhanced interoperability as a measure of success.

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Memory Loss—Meditation to the Rescue

by Ram

Yellow Leaves by Melina Meza

Alzheimer's disease (AD) is an irreversible, progressive neuro-degenerative disease that is characterized by severe memory loss, unusual behavior, personality changes and a decline in thinking abilities. Death of neurons in key parts of the brain harms memory, thinking, and behavior. Neuronal death in the hippocampus area of the brain triggers short-term memory failure, and often the person's ability to do familiar tasks begins to decline as well. Alzheimer's disease also attacks areas of the cerebral cortex responsible for functions such as language and reasoning. Thus AD patients gradually lose language skills and judgment. Personality changes, emotional outbursts and disturbing behavior, such as wandering and agitation, appear and can happen more and more often as the disease runs its course. People with AD eventually require comprehensive care, so the disease presents a considerable problem in patient management. It is believed that therapeutic intervention that could postpone the onset or progression of Alzheimer’s disease would dramatically reduce the number of cases over the next 50 years.

While mutated genes may contribute to the development of Alzheimer's, scientific evidence shows that genes are neither necessary nor sufficient to cause the disease. Environmental as well as life-style practices may also contribute to the disease progression. There is growing evidence that an epidemic of AD may be around the corner and people are rightly concerned, since it threatens to spike in prevalence as the population steadily ages. The significant growth in the population over age 85 that is estimated to occur between 2010 and 2030 (from 5 million to 9 million) suggests a substantial increase in the number of people with Alzheimer's. AD affects over 5 million Americans--there is neither a cure, nor treatment to halt the progression of symptoms. The drugs currently available to treat the disease address only its symptoms and with very limited effectiveness.

Most of us can avoid the mind ravaging effects of AD by making healthy changes in lifestyle, remaining active, achieving ideal weight, reducing stress, and in some cases, supplementing with a diet, vitamins, herbs and/or nutraceuticals that are recommended to you by a physician or licensed practitioner. The brain, like muscles in the body, requires exercise to remain strong in function. Stimulation of the brain increases the branching of brain cells that support cognitive function, and these beneficial effects can be seen in people of all ages. Thus, it is important to pursue intellectually challenging activity throughout life. Maintaining mental agility and learning new tasks as we age is will also contribute to our own well-being and independence. This was clearly articulated by Baxter in his post The Importance of Independence and Nina in her post What is Healthy Aging, Anyway? as they defined healthy aging.

Meanwhile here’s some good news for us yogis with regard to AD. A new pilot study led by researchers at Beth Israel Deaconess Medical Center suggests that the brain changes associated with meditation and stress reduction may play an important role in slowing the progression of age-related cognitive disorders including Alzheimer's disease. The authors of a new research article demonstrated that stress reduction through meditation also improves cognitive reserve.

Approximately 50 percent of people diagnosed with mild cognitive impairment—the intermediate stage between the expected declines of normal aging and the more serious cognitive deterioration associated with dementia—may develop dementia within five years. Additionally, as people with mild cognitive impairment age, there's a high correlation between perceived stress and AD. The authors wished to know if meditation reversed this process. They evaluated adults between the ages of 55 and 90 and included 14 adults diagnosed with mild cognitive impairment in the study. All participants were randomized to two groups: one group that participated in Mindfulness-Based Stress Reduction (MBSR) using meditation and yoga, and a second control group that received normal care. The study group met for two hours each week for eight weeks. They also participated in a day-long mindfulness retreat and were encouraged to continue their home-practice for 15 to 30 minutes per day. All participants underwent a functional MRI (fMRI) before the onset of the study and then again after eight weeks to determine if there were any changes in the structures of the brain or in brain activity.

The results of MRI imaging showed that the group that engaged in MBSR had significantly improved functional connectivity in the hippocampal areas of the brain that is responsible for emotions, learning and memory. Furthermore, those who practiced MBSR experienced less degeneration of the hippocampus. In addition, the data also suggested a trend toward improvement for measures of cognition and well-being.

What a cheap but effective method to reduce hippocampal degeneration and improve functional connectivity in the same areas of the brain that is affected by Alzheimer's disease! Meditation and yoga are some of the simplest intervention modalities with very little downside that may provide real promise for AD individuals that have very few treatment options. In addition to beneficial changes in the brain, yoga and meditation will stimulate the three aspects of healthy aging namely: decreased morbidity, independence and mental equilibrium (equanimity). Indeed, a very good deal!!

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Bhramari Pranayama with Mudras

by Timothy

Recently in a post (Pranayama for Everyone), I wrote about the "buzzing bee breath," Bhramari. I taught a simplified version so that people could get used to it, and feel this practice's almost immediately palpable soothing effects. A reader wrote in with a question about the mudra (in this case meaning a hand position) often taught as part of the practice. So today, I'll teach two more advanced versions of Bhramari, in which the hands are used to deepen the effects.

The fifth limb of the eight-limbed path of yoga as taught by Patanjali is pratyahara, which I like to translate as "turning of the senses inward." Most of us living in the modern world lead lives of nearly constant sensory overload. Phones ring and buzz, TVs blare in the background, and even gas pumps impose video commercials on us. It's hard to escape the visual and aural onslaught. A beautiful antidote is Bhramari, particularly when it's taught with Shanmuki mudra.

Shanmuki mudra is designed to close the gates of perception: the ears, eyes, nose and mouth. It noticeably heightens the power of Bhrmari to internalize the awareness, and you'll notice that the buzzing sounds louder. But before we try the full mudra, let's begin with a modified version.

Bhramari with Modified Shanmuki Mudra

Sit in a comfortable seated position, with the spine upright but relaxed. Place the pad of each index finger on its respective ear, on the tragus, the skin-covered tab of cartilage near the front of the ear, just above the earlobe.

Using gentle pressure, use the tragus to block sound from entering the ear. Try a few rounds of Bhramari, making a medium-pitched buzzing sound on each exhalation. Compare the effects when you occlude the ear and when you lift the fingers.

Bhramari with Full Shanmuki Mudra

In full Shanmuki mudra, instead of the index fingers, use the tips of the thumbs to push down the tragus. The index fingers exert mild pressure on the upper, inner eyelid. Be careful not to press too hard. You want the pressure to feel soothing to the eyes. The middle fingers are placed on either side of the nose, above the nostril and below the nasal bone. You'll know you're in the right place, when gentle pressure on the fingers slightly occludes the passage of air through each nostril. The ring and pinky fingers are placed on either side of the midline just above and below the lips, respectively.

Once you've successfully got the mudra in place, try anywhere from one to five minutes of Bhramari, then lower the hands. You may want to continue to sit in meditation for a few minutes after you finish.

Therapeutic Benefits

Bhramari very quickly shifts the autonomic nervous to parasympathetic dominance. The practice can be useful for anyone with a stress-related condition, and particularly when demands and sensory input make you feel overwhelmed. It may be especially useful conditions like anxiety and insomnia, and even autoimmune conditions.

If you're using Bhramari to reduce symptoms of a cold or sinus infection, either skip Shanmuki mudra entirely or only use the modified version above. Ditto if you feel claustrophobic with the mudra.

While high blood pressure can have multiple causes, many cases of so-called "essential hypertension" (which make up the vast majority of cases), are characterized by heightened activation of the stress response. Thus the regular, ideally daily, practice of Bhramari and other calming yoga techniques may be very effective both at keeping your blood pressure down, and helping reduce it if it's high.

Note from Nina: For more about the yogic approach to high blood pressure, please check out Timothy's upcoming webinar on Yoga U, at an online educational resource. It will be held on two consecutive Saturdays at 12:30 eastern and 9:30 pacific time, starting November 30, 2013.

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Friday Q&A: Kyphosis (Dowager's Hump)

Q: I teach chair yoga for older people. Several of my students have pretty bad kyphosis, a rounded curve in the upper back. They are not yet into a dowager's hump but they are on the way. When we do down dog with a chair, their upper backs are very humped. If I have them try to do cat/cow stretches with hands on the chair seat, their upper backs barely move. I have suggested that they try to lie on their backs with a small blanket roll under the bottom tips of the shoulder blades. Do you have any suggestions for how they might try to reverse this curve or at least stop it from getting worse?

A: This is an interesting question: what to do with the student who has kyphosis of the thoracic spine, the part of the spine in the area of the rib cage? What can we do as yoga practitioners to prevent the progression of the spinal changes we are seeing, and is it possible to reverse the excessive posterior curve in the upper back?  And should we be more attentive to this area when we are younger and possibly avoid this kind of change in the upper back (yes!)?

As we have discussed in the past, the normal anatomy of the spine involves a gentle, undulating set of curves from head to tail. From the backward curve of the back of the skull, as we move into the cervical (neck) spine, the spine curves forward toward the front of the body.  As we travel down into the thoracic (rib cage area) spine, there can be a natural backward curve, although in indigenous peoples and from ancient sculpture there is evidence that minimal curve in this area might be a healthier variation (see the work of Esther Gohkale). As we proceed further south and enter the lumbar (lower back) spine, the spine curves toward the front of the body once again. Finally, the sacrum curves backwards to complete the serpentine trail of the spine.

According to the Mayo Clinic website (I love these folks!):

“Kyphosis is a forward rounding of your upper back. Some rounding is normal, but the term "kyphosis" usually refers to an exaggerated rounding — sometimes called round back or hunchback. While kyphosis can occur at any age, it's most common in older women where the deformity is known as a dowager's hump.” 

Today, I am interested in kyphosis that occurs in older adults. In my experience, I have encountered this pronounced curve in both older men and women. The Mayo clinic notes that it occurs more often in women, likely due to the earlier onset of osteoporosis (OP) in women. What’s the OP connection?

The most common site of fracture in people with osteoporosis is the spine, and more specifically the thoracic spine. The typical fracture in the area is called a wedge fracture, in which the body of the vertebrae, that kidney bean-shaped biggest part becomes so thin that the front part collapses, and when seen from the side, it looks like a wedge. If you get several of the vertebrae in a row doing that, then the whole upper spine begins to bow forward like the Kokopelli image.

In some instances this will result in stiffness and difficulty maintaining an upright posture, and for some pain will also arise. Along with pain, in more severe cases of kyphosis, the change in spinal curve can affect your lungs, nerves, and other tissues and organs. So we need to do at least one important thing before we start moving these students of our reader around a lot: have them see their family doctor for an X-ray of the thoracic spine to see if fractures have already happened and get a DEXA scan to rule out OP if this has not been done. Once you know their OP status, you can make better decisions around yoga poses and practices.

Two other important factors that can contribute to kyphosis in older adults are disc degeneration (we have written about this, too) and cancer and cancer treatments (which can weaken the vertebrae and contribute to fractures as well).

Your western doctor may recommend certain treatments:

• If there is OP present, medications to treat osteoporosis might be prescribed.
• If pain is present, pain relieving meds could be recommended. 
• If the person’s condition is compressing a nerve or causing some other significant problem, surgery to fuse bones could be suggested, but the risk of complications is high and tends to minimize this option.
• Physical therapy exercises are prescribed to improve flexibility in the spine, as well as ones to strengthen the abdominal muscles to help support better posture.

Obviously, this last area, improving flexibility of the spine and strengthening abdominal muscles, is where yoga practice could be helpful.

If you don’t yet have a copy of Loren Fishman’s book Yoga for Osteoporosis and you are working with older adults, perhaps today’s the day to order it! It is a good resource of suggested poses and ways of doing them that you will likely find invaluable. A valuable piece of advice from the book regarding patience with these students is:

“Although yoga can be slow, requiring months or even years to achieve major effects, the trip is pleasant…”

So, with patience in mind, in regards to the reader’s observations, I’d suggest that for Downward-Facing Dog with the chair, if they are putting the hands on the seat of the chair, bring them up to the back rung, and if already on the back rung, do a higher version of Half Dog Pose at the Wall.

Half Dog Pose at the Wall

Let them bend their knees a bit and focus on lengthening their spines to whatever degree they can pain free. Even if not much seems to be happening in Cat/Cow pose, keep doing it anyway. I like the effect of dynamic movements like that for loosening tightness up gently. Along those lines, have them stand in Mountain pose with their backs to the wall, perhaps with the kyphosis lightly touching the wall. Then have them inhale one arm forward and up overhead and exhale it back down. Repeat with the other arm. Do several sets of these. The mere act of taking the arm overhead will begin the encourage extension of the upper back, exactly what you are looking for here, and strengthen the upper back muscles that assist in this goal. You could obviously do this sitting as well. 

If they can easily get down to the floor for Savasana, I find that no lift is needed under the thoracic spine, but a lift is definitely needed under the head so it stays level with the chest. Over-extending the neck has its own set of worries you don’t want to cause! In that reclining position, you can again have them work the arms as we did in Mountain pose.

To strengthen the abdominals, you could create a variation of Boat pose (Navasana) done sitting at the front edge of a chair, lifting one bent leg up a few inches and holding it in position for a few breaths, then lowering that foot to floor and repeating with the second leg. Again, if they can get to the floor and you can teach them Locust pose (Salabasana) or even one-legged Locust (which takes the spine into extension), you can have them do that at home or even in bed if they have a firm mattress.

One-Legged Locust Pose

I’ve already gone on a bit too long today, but I do believe that by intervening now and getting these people to practice at home as well as in class, you have a good chance of stopping the progression of the kyphosis and in some cases, where no wedge fractures have altered the anatomy, maybe even helping to reverse it! Please let us know how things go.

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Meeting Death at the Front Door

by Nina 

by Melina Meza

"Research shows that most Americans do not die well, which is to say they do not die the way they say they want to — at home, surrounded by the people who love them. According to data from Medicare, only a third of patients die this way. More than 50 percent spend their final days in hospitals, often in intensive care units, tethered to machines and feeding tubes, or in nursing homes.” —Dan Gorenstein from “How Doctors Die”

Yesterday I heard a very moving piece  How Doctors Die on NPR that made me think again about an issue close to my heart: being able to face death with courage.

My mother died of breast cancer at age 85, and she was able to die with hospice care at home without any invasive procedures, any time in a nursing home or being “tethered” to any machines. Because I was talking to her doctors for her and coordinating her care, I can testify that this was only possible because my mother was clear-eyed about her condition and was willing to admit she had a terminal condition. In fact, one of the requirements for beginning hospice care is for the patient to agree to no more potentially “curative” treatments (hospice provides comfort care only). So this means being willing to face the fact that you are dying.

The piece on NPR and the companion piece in the New York Times article How Doctors Die: Showing Others the Way made the same point. The doctors in the article were able to choose the way they died—and lived while they were in the process of dying—because their medical knowledge helped them face the truth of their situations. Realizing that her condition had become terminal, Dr. McKinley decided to turn down more treatment and to begin hospice care.

"What Dr. McKinley wanted was time with her husband, a radiologist, and their two college-age children, and another summer to soak her feet in the Atlantic Ocean. But most of all, she wanted “a little more time being me and not being somebody else.” So, she turned down more treatment and began hospice care, the point at which the medical fight to extend life gives way to creating the best quality of life for the time that is left."—Dan Gorenstein

While some people do very much want to die in a hospital, I believe that most of us do not. And to make that happen, either for ourselves or for our loved ones, we must be as clear-eyed and honest with ourselves as my mother and the doctors portrayed by NPR and the New York Times were. That takes a lot of courage.

"BRAVE. You hear that word a lot when people are sick. It’s all about the fight, the survival instinct, the courage. But when Dr. Elizabeth D. McKinley’s family and friends talk about bravery, it is not so much about the way Dr. McKinley, a 53-year-old internist from Cleveland, battled breast cancer for 17 years. It is about the courage she has shown in doing something so few of us are able to do: stop fighting." —Dan Gorenstein

How can yoga help you be brave? Of course I can’t write about my own death, but I did help both my parents die at home (and have all the clear-eyed conversations that entailed), so I know it is a very stressful process. So I expect that stress management, of whatever kind works for you, would be valuable. I tried to stay as calm as possible when I was helping my mother and found myself every day doing very long sessions of Legs Up the Wall pose combined with breath work (extended exhalation). And sometimes when I’m doing my breath work these days, I consider that this is a practice I will probably have access to until the very end. For information on various options for stress management, see The Relaxation Response and Yoga. Anxiety—which is fear of things to come—can also be a problem, and yoga can help soothe you when you’re anxious. Baxter and I have done a whole series of posts on anxiety, so see Yoga Solutions for Anxiety and check the index on the right side of the blog under the label "anxiety."

I also hope that yoga philosophy will come to my aid. The Yoga Sutras actually describes abhinivesha or “clinging to life” as one of the impediments to samadhi, describing it as inherent tendency.

Yoga Sutra 11.9 [The tendency] of clinging affects even the wise; it is an inherent tendency.  —trans. by Edwin Bryant

But the Yoga Sutras also tells us that truthfulness (the yama satya) is a crucial part of yoga practice. This is one aspect of the universal “great vow” that is the second branch of yoga.

Yoga Sutra 2. 36 When one is established in truthfulness, one ensures the fruitions of actions. —trans. by Edwin Bryant

And it seems that truthfulness—being willing to hear the truth as well as to tell it—will help you face your death and die the way you want to, and to be able to help your loved ones as they die. Just the other day a friend told me how she was trying to help a friend of hers who was dying. “But he won’t admit it to himself,” she told me. “And that makes it impossible for his friends to help him."

So it's my feeling that you have face the truth yourself. That you have to tell your family the truth. That you have to insist your doctors—and your loved ones—tell you the truth. And if you are helping someone else who is dying, facing the truth about their condition will allow you to provide them with the help they need.

In the audio version I heard, Dr. McKinley called her approach to her impending death as “Meeting Death at the Front Door.” Besides being able to do the things you love as you age (see Being Able to Do What You Love), isn’t an essential part of healthy aging being able to die the way you want?

"The front door at Dr. McKinley‘s big house was wide open recently. Friends and caregivers came and went. Her hospice bed sat in the living room. Since she stopped treatment, she was spending her time writing, being with her family, gazing at her plants. Dr. McKinley knew she was going to die, and she knew how she wanted it to go.

“It’s not a decision I would change,” Dr. McKinley said. “If you asked me 700 times I wouldn’t change it, because it is the right one for me.”

Dr. McKinley died Nov. 9, at home, where she wanted to be." —Dan Gorenstein

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