Pain, Pain Go Away: Palliative Care for San Francisco Elders Goes Beyond Meds

Image: Palliative care patient Gil García García with his niece Fatima

Photo: Norbert Charles is a volunteer at the Curry Senior Center in San Francisco. Recently diagnosed with cancer, he now receives palliative care at Curry. (John Burks/Central City Extra)

SAN FRANCISCO–Norbert Charles worked for seven years as a volunteer at Curry Senior Center, helping mostly low-income Tenderloin neighbors with failing health. He showed them movies, took them on field trips, helped with bingo. A strapping big guy, everybody knew his name and his booming laugh. “Made me feel good to be here and help out,” Charles says, “and I tried to show that.”

Then, six months ago, his own health took a stark downturn. Heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, and stomach and colon cancer all struck at once. He’s lost 50 pounds, down from 182, and now cruises Curry Center in a wheelchair rigged with an oxygen tank.

“One thing that hasn’t changed is that I’m here just about every day, hanging out with my people,” Charles, 67, says, smiling. “Wouldn’t rather be anywhere else. With my mama long gone, all my family gone, nobody but me, Curry is like my family. They make me feel needed. Being alone and being lonely — that’s two different things.”

On this sunny November day he is stationed near the Curry clinic’s entryway, just across from the receptionist’s desk, serving as unofficial greeter, ever positive. Now he’s the beneficiary of the sort of volunteerism he once donated — and receiving the sort of health care most of us eventually require.

Earlier this year, this reporter attended a symposium at Stanford Medical School on health care for seniors — emphasizing palliative care and hospice. Objective of the New American Media symposium, sponsored by the California Health Care Foundation, was to help journalists better explain palliative care — pain management and more — to their communities. Only a relative handful of Americans understand that palliative care is different from hospice care, surveys show.

Comfort and Curative Care Together

Senior health providers in San Francisco’s Central City area are keenly aware of the differences, and have been for decades. Charles, for example, receives both palliative “comfort” care and curative care: Palliative, so he hurts less; curative, to halt or at least slow down his several diseases. He gets along now on eight separate curative prescriptions and two palliative (Tylenol, oxycodone). A similar combination of curative and palliative care is credited with having kept human rights icon Nelson Mandela alive at 95 through repeated hospital stays for lung disease.

Palliative care is a staple treatment at central city seniors centers, providing relief from the pains and stresses of chronic lung, liver or kidney disease, chronic heart failure, AIDS, cancer, dementia or stroke. It’s part of a well-rounded approach, combining medicines with good nutrition, case management, housing, behavioral health and social programs.

It’s illuminating to compare a recent New York Times report on palliative and hospice care, which comes in the last months of life, with what we found in the Tenderloin. The Times showed that the great number of for-profit medical service regard palliation as an add-on; Tenderloin caregivers are among those in a growing national movement who tend to see these treatments as interconnected in the fabric of overall health care.

The next step is hospice. Patients whose illness becomes terminal move on to hospice care, provided in a stress-free, peaceful setting, often with friends and family in attendance. Palliative care makes the patient as comfortable as possible during her/his final days. Hospice is available free in California to those with Medicare and Medi-Cal.

Norbert Charles was set to undergo cancer surgery a few days before Christmas and, depending on the outcome, hospice could eventually be in the cards. But not yet. A friend at his single-room-occupancy (SRO) hotel, Terrie Wolfe, likens Charles to a Timex watch — “He takes a lickin’ and just keeps tickin’.” An athlete (track, football) as a youngster at long-shuttered Poly High, and a Vietnam vet, he maintains that warrior spirit.

Angry tears stream down Charles’ face, recalling his Vietnam saga.

As he tells it, his hopes of competing in the 1964 Olympics — a 6-feet-7 high jumper in high school — were dashed when he was drafted. He says he served in Vietnam with the 82nd Airborne for nearly three years. Then was discharged after he came home to San Francisco, A.W.O.L., to visit his dying mother. Today the military admits to no record of his service, he says, cutting him out of benefits he deserves, leaving him anguished and hurt, “a skeleton now that they can just throw away.”

Like many Tenderloin seniors, he pieces together his medical care, visiting S.F. General and California Pacific hospitals, plus Curry’s primary care clinic, which is run by a University of California, San Francisco, faculty member. He takes his meals at both Curry and the nearby Glide Foundation, augmenting them with canned food and microwave concoctions.

Culturally Comfortable

Daily, scores of Tenderloin and South of Market seniors are transported to adult day care facilities elsewhere in the city. Self Help for the Elderly operates adult day care centers at several locations in San Francisco.

Sarah Chan is program director at Self Help for the Elderly’s center on 22nd Avenue in the Richmond District, where nearly a third of the 156 daily clients are Tenderloin residents. This bright, cheery place unites them with friends, mostly Chinese American, and staff they’ve known for years.

Here is where they can get a free lunch, often traditional Chinese fare, and clients and staff converse in appropriate regional dialects. Everything is done to assure their cultural comfort while they receive treatment. The feeling is upbeat. This, too, is palliative care.

“I tell staff to be as joyful as possible,” says Chan. “We want our clients to feel like they’re at home, and I think most days they’re happy to be with us and with one another. Happiness is critical. It promotes good health.”

In the outer lunchroom, a convivial buzz prevails. It’s quieter, by design, in the separate inner dining room for dementia patients, who require less distraction. Some of the Alzheimer’s sufferers are hand-fed.

Chan confers regularly with caregivers to determine which clients are showing onset of dementia. “Clients cannot tell us,” she says, “so we assume a sort of parental role.”

This is part of palliative care for very ill Chinese elders. They are not in pain, but they are in need of comfort. Culturally, it puts them at ease.

Many of Chan’s clients go on to hospice in their last months of life. She views this as a continuation of the care her center provides. “We try to make what remains of their lives as satisfying as we can, and hospice is a continuation of that treatment.”

City Official a Senior Care Pioneer

The modern era for senior health care in San Francisco started in the Tenderloin in 1972 with the North of Market Health Council. Founder Francis Curry, MD, then the city’s public health director, was a pioneer in bringing medical care to low-income elders. His main concern: Many Tenderloin elders suffered alone, isolated from friends, family and care.

The Health Council’s operation was nothing fancy: one doctor, one nurse, in a storefront. Curry Senior Center has grown enormously in 41 years, now providing primary care for 1,600-plus clients, annually hosts 1,700 social activity hours, served 49,000 breakfasts and 61,000 lunches last year, and houses formerly homeless seniors.

Cantonese, Lao, Vietnamese, Mandarin, Russian, Spanish and Tagalog are all spoken at Curry, representing the panoply of Tenderloin cultures.

In 1982, Curry Center was a founding partner in the San Francisco Community Clinic Consortium (SFCCC), whose 10 partner clinics now serve more than 87,000 low-income, uninsured, underserved San Franciscans each year.

David Ofman, MD, appointed consortium interim director last month, has lived much of this history, having run North of Market Senior Services and Curry Senior Center, plus a variety of safety net projects.

“Seniors in the Tenderloin are not the same as 31 years ago, when our consortium began,” says Ofman. “There’s a lot more homelessness, a lot more mental illness, a lot more substance abuse, and AIDS was barely on the horizon back then. They’re living longer, they’re older, more frail. And we have many more Southeast Asians now — a positive influence, bringing stability to the district.

“We’re better able to serve them now, though,” says Ofman. “There’s been expansion of service across the board. There are a lot more supportive services.”

During the ’80s, large numbers of ailing seniors were holed up in hotels, hidden away. Plus, there weren’t that many caregivers back then, Ofman recalls. Now they’re more likely to seek help. “There are still some who refuse treatment, but I can’t recall the last time we discovered someone seriously ill, in need of care, who didn’t get it.”

Hospice care has made big strides since 1982, when Medicare approved it for those receiving only comfort care—with no medical treatment—in their last six months. But even then it took a backseat to curative treatment. Now, palliative care is offering both comfort and medical care as needed.

“Quality of life has assumed a role in treatment as important as controlling disease,” Ofman states.

John Burks wrote this article for Central City Extra through a California Healthcare Foundation Journalism Fellowship, a project of New America Media in collaboration with the Stanford In-reach for Successful Aging through Education Program.

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About John Burks

John Burks, Contributing Writer, City Central Extra, San Francisco. Burks’ career has spanned magazines, newspapers, books and websites, taking him from newsrooms to academia and back. He served as a Newsweek correspondent, Rolling Stone’s first managing editor, and investigative reporter for the San Francisco Examiner and Oakland Tribune, established San Francisco Focus (now San Francisco Magazine) as the Bay Area’s dominant magazine. Now an emeritus professor at San Francisco State University, Burks he created both SFSU’s magazine sequence and its online news site—the first in the nation. As chair of the Department of Journalism there, he led a state and national effort to upgrade journalism curriculum. The long-time president of the San Francisco Study Center, he has helped nurture Central City Extra, which the nonprofit publishes, as it has taken top Northern California journalism awards.