B.C. physician John Sloan has seen it time and time again. An elderly person, usually living on her own, takes a turn for the worse. Maybe she's suddenly short of breath or gets an infection.
It's a weekend, so her doctor calls an ambulance or tells her family to take her to the hospital, where she lies around in ER for 12 or 15 hours before being admitted. The hospital does a battery of diagnostic tests, many of which lead to further tests. It turns out that this little old lady has heart failure, vascular dementia, osteoporosis, diabetes, high blood pressure and arthritis. Many of these conditions have been previously diagnosed, and none are curable. Nor are they particularly unusual in an 86-year-old. After two or three weeks of essentially pointless treatment, the patient is sent home with a vast array of pills. Yet, despite all this medical care - in fact, because of it - she'll probably get home in much worse shape than she was before.
Dr. Sloan treated the elderly at home for many years. (Yes, he made house calls!) His recent book, A Bitter Pill, is an utterly convincing indictment of the way we're wasting money on useless care for the elderly, while making their lives worse. It's essential reading for anyone who's interested in health-care reform, as well as for anyone who's responsible for an elderly person or anyone who is or will become one.
The essential problem is this. An elderly person's real needs are fundamentally different from the needs of all the rest of us. The critical-care system is designed for prevention and rescue. Its carefully developed, standardized, science-based procedures work well for the middle-aged. But no two fragile elderly people are alike. Their diseases are beyond fixing. Their real issues are comfort and function, not rescue and repair, and where they really want to be is in their home. Yet, we still try to cure them. Rather than attending to their comfort, we overmedicate them in a well-intentioned effort to improve their futures.
The last thing most elderly people need in a crisis is a hospital. Usually, they need a home-care family doctor who knows them well, a nurse, and probably a social worker to analyze the crisis and get home support. Instead, they get emergency treatments, dozens of tests, referrals to teams of experts, special monitoring equipment, and many, many types of drugs. As long as we misunderstand what they really need, argues Dr. Sloan, "we will keep on trying to fix some poor old lady's not being able to get to the bathroom by putting her in a $1,200-a-day hospital bed with iron side rails."
In his view, the hospital is one of the worst places she can be. A hospital stay will almost certainly cause acute stress, discomfort, depression and further loss of function, to say nothing of hospital-based dementia and hospital-acquired infections.
But if hospitals are brutal to little old ladies (and men), the reverse is also true. Visit any general medical ward, and you'll see why hospitals are in gridlock. The beds are full of old people, and lengths of stay are long. It's not that these people have nowhere else to go. The problem is, they're trapped by standard protocols and procedures that keep them imprisoned until they're "better."
You'd think this problem would be easy to fix. More home care! People have been saying this for 20 years, but it never happens. Dr. Sloan has been involved in the start-up of no fewer than four potential government-funded programs to provide genuinely comprehensive care and support for elderly people at home, and every one has collapsed. Why? He thinks that, at bottom, it's our individual reluctance to let go of the "prevention and cure" approach to care, even when it's disastrous.
Meantime, he offers a few tips. Do anything you can to keep your fragile mum out of the hospital - unless there's a clear goal that can't be met any other way. No drugs that don't make her feel better. If she's still in the hospital and you can't figure out why, and you think she'll be better off at home, take her home. She'll be glad you did.