Gertrude (not her real name of course) is a just-about-90-year-old lady with red hair living alone in a small one-bedroom apartment overlooking the beach. The place is… not cluttered exactly, but packed with mementos: photographs and paintings on the walls, small objects on every horizontal surface, a cat. Gertie has been an entertainer most of her life and sang and danced for the troops overseas during World War II. “God we used to have fun,” she says about those days. She’s quite a doll.
But also high-strung. She gets worried when things don’t go well, hates her indwelling catheter which she can’t do without, wishes she didn’t have to walk with a walker, and isn’t sure why she’s short of breath (I’m not either).
A couple of months ago Gertrude woke up with a pain in her right groin. I was pretty sure it was a pulled hip-flexor muscle from a forgotten awkward turning-over in bed, and for a while she was fine with some Tylenol. But then it got worse. Eventually we bit the bullet and Gertie went over to the emergency room where the right groin area was imaged (twice because the first scan wasn’t clear). Meanwhile I had slowly increased the dose of her morphine-related medicine to try and control the pain and keep her on her feet.
But things did not go well, and finally when the medication was causing confusion and still wasn’t controlling the pain there was no choice but for Gertrude to be admitted to the hospital to see if we could find out why she was so sore and try to fix it. Everybody including her regretted this and I thought to myself that this could be the last she saw of her beloved apartment.
The hospital admission featured the usual: multiple specialist referrals, every kind of imaging of the groin area and everywhere around it, and not much attention to getting or keeping her mobile. After two weeks still nobody knew the cause of the pain although there were plenty of theories, and Gertrude was spending more and more time in bed. A geriatric specialty team including occupational therapist and physiotherapist wanted to send her to a different institution that focuses on rehabilitation, but I was worried that the rehabilitation would consist of walking once a day and lying in bed the rest of the time.
But a couple of positive things happened. A capable resident doctor with my encouragement switched the morphine to gabapentin, a drug effective for anxiety and also pain coming from nerves, the confusion mostly cleared, Gertrude was eating better and starting to stand up.
Still the geriatrics team didn’t feel she was safe to go home. What if there was a fire? How was she going to use the toilet? When I went in and walked her, she was almost back to her old state of being mildly forgetful and slow and a bit unsteady walking with her walker, but she was making progress. Our community physiotherapist saw her and agreed that the risk of sending Gertrude home to her familiar surroundings was less than the risk that she would get stuck in the hospital or rehabilitation institution and never get home at all if things continued as they were.
So in the face of persisting disagreement with the hospital professionals, we set up temporary four-times-daily home help, organized her medication and mobilized her family to visit, and sent her home in an ambulance. Three days and counting, she’s doing fine.
What is this huge and consistent difference between the way hospital professionals understand risk and safety, and the way equally-trained people who work in the community see it? Why does the hospital seem at times to function like a corrections facility? Could the problem be the people in hospitals? No! They tend to be incredibly good at what they do, highly-motivated, and caring about the people they serve. I think it must be the hospital policy of avoiding risk, and the hospital mind-set that in my opinion incorrectly believes that being in a hospital is somehow fundamentally good for people.
It isn’t. Underlying this thinking is the idea that society must contain the taboo reality that every frail person is subject to crisis (after crisis), and then they die. And one of the functions of hospitals is to accomplish that. I wonder how badly we really need that basic falsehood?
What should we do? Start by crossing the hospital-community boundary professionally. We wild and woolly housecall folks need to get back into the hospital in a friendly consultative way, but we also need hospital people who understand the community mindset. Some internal medicine geriatrics doctors get this, and I could imagine a hospitalist with experience in the community doing it too. Elderly person going nowhere in a $1200-a-day bed who wants to go home but looks like an accident waiting to happen through the hospital’s glasses? In-hospital community consultant sees him, does some shared decision-making with him and family, everybody understands and documents the risk, and back home he goes.
Kindness, collaboration, honesty, good healthcare practice, and needs being met. All on a reasonable budget.
John Sloan is talking “quality of life” and the importance of individualized plans of care for elders. Health care professionals must work together to provide this.
At first I thought this was another of Dr Sloan’s case histories, with a happy ending because the frail old lady went home again from the hospital. But there is an important idea in the closing paragraphs. Dr Sloan calls it ‘crossing the hospital-community boundary professionally’. He rightly wants to challenge the idea that Sunshiners’ lives consist only of crises and waiting for death.
Here is a suggestion for interested medical professionals to see how frail older folks might manage in the community: visit an Adult Day Centre (as they are called in Vancouver). The elderly clients are referred by social workers because they are suffering significant dementia and physical frailty. Staff provide mental and physical stimulation, fun and friendly support in a group setting. Day Centres have a medical chart for each client; arrangements might be made to share these with visiting medical professionals.
These Day Centres are one of the cheapest and most effective tools for keeping older folk in the community and out of care homes. They deserve much better public support. But that is another huge topic.