Working in a big emergency room as part of a team that tries to intercept unnecessary hospital admissions of frail elderly people, I seem to find there are fewer elderly people who call an ambulance themselves and are brought to the emergency room, than elderly people who turn up because somebody else thinks they should be there. That somebody may be their family, but increasingly in my experience it’s their family doctor.
An 88-year-old lady whom the emergency room physician wanted to admit to the family practice unit to “sort things out” had come to the hospital because of trouble breathing, but she didn’t seem to have much wrong with her on paper. Her daughter, who had left to go to work, explained that her family doctor had sent her in to see the specialists and have some more tests. The elderly lady had trouble getting around at home and was a little bit confused, but since coming to the emergency room her blood tests, chest x-ray, blood oxygen saturation, and physical findings weren’t bad enough to explain her complaint that she couldn’t get her breath and the fact that she was breathing relatively quickly.
I wanted to find out if she still had a normal blood oxygen when she exerted herself, and so with the help of a physiotherapist I sat her up in bed, had her stand up and grip onto a 4-wheeled walker, and took her on a little stroll out into the emergency back-ward hallway. She did surprisingly well.
When she got back to her bed area, I sat her in a chair and chatted with her. The fast breathing had settled down, and she said she felt a bit better. “Nobody has ever talked to me about my breathing trouble before”, she said. “It seems strange to say, but I feel less worried about it now that I know nothing more can be done to improve it. And I didn’t understand that if I came into the hospital I might get worse instead of better.”
This lady’s family doctor had sent her to the hospital because several months of investigation of her heart and lungs, including evaluation by specialists and trials of multiple medications, had not turned up a cause for her distress. Having spent many years in a family practice office, I understood the doctor’s problem: the prescription his patient needed was not available in any pharmacy. It consisted of helping her to understand that her expectation, which included (without her really knowing it) being healthy and feeling like a fifty-year-old again, wasn’t ever going to be met. It would have taken the doctor a lot more time than he could spend on an office appointment, and some personal moral weight-lifting, to explain to his patient and admit to himself that there wasn’t much he could do.
I don’t blame the family doctor or the emergency room specialist. These two capable kindly people were working hard to get their jobs done well. The family physician was practicing evidence-based preventive care for his patients, and the emergency room doctor was trying to assure the safety of all the worried, sick, and injured people who came to the hospital looking for help.
And I’m not suggesting that all difficult clinical problems can be solved by a few minutes of good honest truth-telling. But once we’ve done everything we can to help someone and it’s completely clear that no amount of doctoring or medicine will be effective, we need to get over our reluctance to use one of our oldest and best treatments: benign and kindly sharing of the burden of inevitability.