Lost Sheep

Well it’s Christmas. And I the sorry lapsed and sentimental secular Christian can’t resist childhood-retrospective feelings. But although I know the suicide rate probably doesn’t really increase much at Christmas, still from my adolescence I am no stranger to Christmas alienation. It’s just an emotionally loaded time when long-past sensitivities crowd life’s center stage.

Along with the observant, we who went to Sunday school might remember a counter-intuitive story Jesus told about a shepherd who left a hundred sheep to the ravages of the night to go find the one who had wandered away. The shepherd tracks down the little lamb and brings her home over his shoulders, and everybody celebrates. Nothing is mentioned about how many of the other sheep temporarily left on their own got grabbed by wolves. Plus what’s this nice smiling boy carrying the little sheep back for? At least some of the people celebrating must have been thinking about her curried or roasted pink.

Never mind. In our benighted contemporary world primary healthcare of frailty tries to gather a similar flock at large in the community and create a virtual fold that protects them from predators, most of whom in this flipped-over virtual parable wait quietly texting on their phones in the hospital cafeteria. And like wild carnivores these specialist doctors are very good at what they do and (seen in the “appropriate” light) could be… cuddly. They are friends of mine. Their hearts beat softly just like any lamb and they snuggle their cubs when they go home at night.

But we feral housecall doctors in our virtual fold community programs are not-yet proven to be what all lost frail homebound lambs need. That’s going to take another year or five. In the meantime, every afternoon there is still a load of busted-up mutton arriving by ambulance at everybody’s emergency room. God protect me from an offensive metaphor: these are real people who will be you and I a decade or four down the freeway: confused, frightened and hurting everywhere with no place else to go for help.

Vancouver Coastal Health in its inimitable way of doing business has first: understood the need including the fiscal one, second: legislated a superficially sensible solution, third: failed to understand the clinical and even administrative detail, fourth: somehow persisted and made it work.

So: I am now part of a team that crouches in the middle of the biggest emergency department in our province and identifies and tries to intercept elderly people who have come to the hospital and who clearly have no reason to be admitted. These frail ones in the traditional process would have been whisked to the family practice or internal medicine floors because what else were we to do with a 90-year-old who is confused, can’t walk, is in pain, and has no capable caregiver or family doctor? Another statistical bed-blocker but much worse, somebody deprived of his or her home and trapped in a technical machine that only makes problems worse.

Instead of that ridiculous and wasteful nightmare, we in our new program try to find a way safely to send these wonderful frail people back home.

Our team consists of a “clinical management leader” (an experienced capable nurse), the “transitional services team”, a couple of equally capable registered nurses who can figure out in a twinkling what services a patient has been set up for in the community and judge what needs to be added, a “quick response team”: savvy and heads-up nurses and occupational therapist who can go out within an hour or two and see an elderly person at home, and (now), a team of family physicians who support the in-emergency group and after-discharge quick response team to keep old people with troubled caregivers, chronic pain, collapsing home services, and a dozen other nightmares that the hospital will only make worse, OUT of the hospital, and safe at home.

We doctors are going to be available 24 hours a day by phone for elderly patients and caregivers who have come to the hospital in crisis but who don’t really have the kind of crisis the hospital can help with, and head back home to deal with it there.

This is one solution for ignored homebound old folks with plenty of problems and no adequately-functioning family physician (I guesstimate there are 1000 or so of these patients in our city of 600,000). They will always suddenly need help when their caregiver burns out with her alcoholism and old personal conflicts with dad, the kindly helping neighbour falls and can’t get to the store anymore, or the granddaughter gets a job in Winnipeg. But I wonder if our emergency-room program is a bit more downstream than it needs to be.

My faithful readers won’t have any trouble guessing what I think the real solution to crisis in frailty ought to be. It’s all very well to prevent the bathroom from flooding by trying to empty the overflowing bathtub with a plastic measuring cup. But how much easier and more effective it would be just to turn off the tap!

Our HomeViVE primary care of the elderly program and others like it does its best to prevent the strange and terribly human disaster as troubled elderly people stuck in their homes have no alternative but to push the 911 panic button when things fall apart. Our patients have had a conversation with us including How do you want to live the rest of your life? What are you are most afraid of? And What do you really hope for at the end of your life?

In the relationship that having that conversation (plus being available 24 hours a day and seven days a week) encourages we think we develop trust that lets older people get off the dangerous and wasteful “we-can-cure-you” hospital critical care merry-go-round, and start dealing with their real priorities in the last weeks and months of their lives.

The Christmas will come when we won’t need to go rescuing lost sheep from the emergency room and the hospital. We will give the gifts they tell us they want, usually in the relative comfort and safety of the place where they properly live.

Even though we are talking here about people, who unlike sheep know perfectly well where they are eventually headed.

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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