Another Jailbreak!

GM “Gord” is 87. He is a proud and accomplished man who was born in the 1920s in small-town Saskatchewan with birth injury to his arms and legs. As a child he could walk and move his arms but wasn’t half as physically capable as other boys his age, and as he describes it “I had to adapt”. In the 1930s he had a paper route, avoided or outsmarted bullies in grade school, and eventually found office work. Later he married briefly, but today lives on his own in a very nice subsidized apartment in Vancouver’s West End.

This brave man refused investigation of medical problems that suggested he might have cancer (“If it’s cancer, it’s cancer. I’ll take the lumps.”), and told our occupational therapist he didn’t need any help in spite of falling every couple of months and gradually losing the use of his arms. I explained to him many times what a cancer death would be like, and estimated his chances of a cure with investigation. He was not interested. He also didn’t want to be in the hospital, having been there before.

About a week ago he fell, and somehow his legs were tangled in a way that scared him, and so when he pressed his Lifeline button and the paramedics came no doubt expecting to lift him back into his chair as usual, he agreed to be taken in to the emergency room and evaluated, worried that something might be broken.

The hospital doctors told me that he had said he thought he needed more help, he couldn’t cope, and that he wanted to be investigated, but he denies saying any of these things. In any case a medical student telephoned me while Gord was still in the emergency room and enumerated his anemia, digestive symptoms, general weakness, and frequent falls. I explained to the doctor trainee that this man had very clear in not wanting to be investigated, not wanting to be given extra help he didn’t need, and not wanting to be in the hospital.

Still, they admitted him to internal medicine. They investigated his diarrhea and anemia (I had already evaluated them), and the social worker, occupational therapist, physiotherapist, and geriatric team were consulted. I got a call from another medical student working with the medicine service, provided him with the same information, and heard about their plans for evaluating his medical problems, determining what his needs were, and straightening out his future life. I heard nothing further for five days.

Yesterday I went into the hospital to see how things were going. Gord was thin and pale lying on a bed, and recognizing me immediately asked if I could get him out of there. I asked him how he was doing and he said “bad”. He looked around to make sure nobody was listening and then said, “I’ve been in bed for nearly a week and every day I get weaker. They won’t give me anything for diarrhea, I have these diapers on like a child, nobody helps me to get up or walks me anywhere, and they keep coming up to me and shaking their heads.”

It wasn’t easy to find the doctors caring for him. Nobody knew the name of the resident and the attending physician wasn’t available. I found the physiotherapist, but she couldn’t get ahold of her occupational therapy colleague on the phone. Eventually we went in and tried to get Gord to stand up and walk, which he managed although fearfully and stooped over. Then the occupational therapist arrived. The plan was to do an evaluation of his safety at home in about four days, she said.

May I be forgiven, at this point I lost it a bit and told the occupational therapist that at the rate he was losing function, by Friday he would be completely bedbound. Fortunately, she was kind and tolerant and (when I apologized) explained on my behalf (to me) that I was just advocating for my patient. Although I appreciated this, something was lost in the translation.

Eventually we negotiated that our home care program occupational therapist would see Gord at home the next day, and that if he could function “safely”, they would discharge him.

Today, I turned up at Gord’s apartment just as his hospital transfer vehicle arrived. He looked like death warmed over as they wheeled him up the elevator and into his apartment, but our OT Dave appeared punctually, and an atmosphere of optimism prevailed. Gord couldn’t sit up in bed and was awkward and dangerous getting himself into the bathroom. As I left for another appointment I was not optimistic.

About an hour later, Dave called me. “He’s fine. He got up in bed, transferred into the bathroom, and walked independently into his living room and sat down in his chair.” I was incredibly elated. Where do people like Dave find the magic? Where do people like Gord find the strength?

Gord understands nobody lives forever, but he now also understands that there isn’t a default rescue that will lead to solutions to all his problems by pushing a button on his wrist. We will try to find a way to support him as he declines, and somehow to help him out of the hospital when things go wrong and he’s inclined to push the panic button.

He thanked me for breaking him out of jail and promised to call me next time he’s tempted to risk hospital emergency room care.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 30 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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