Lying on the backboard, a frail little old lady moaned with discomfort.
She had fallen beside her bed in the nursing home and was then tightly bound by straps onto the backboard, a cervical collar pushing her chin up and holding her immobile. A person not familiar with modern medicine might think the ensemble looked like a torture device. Indeed, it can be. Not only uncomfortable, a backboard is made of hard plastic and can quickly cause pressure ulcers even in younger patients. It’s all too common a scene.
Looking at her, I thought about all of the confused, weak, elderly patients subjected to aggressive care and why it happens. They don’t come to us merely due to the vagaries of age, gravity, and balance. They are sent to us because of the confusing way we mix medicine with legality, anxiety, and unexamined expectations.
If the 95-year-old Alzheimer’s patient has a cervical spine fracture, will we subject him to surgery? When the 80-year-old woman with multi-infarct dementia has a thoracic spine fracture, will the surgeons intervene? And if a lucid 100-year-old man has a brain hemorrhage, will he be whisked off to the operating room so neurosurgeons can drill a hole in his skull?
We are actually being cruel, and we neglect common sense and kindness, when nursing homes send their patients to the emergency department for extensive (and expensive) evaluations of marginally treatable conditions.
In our fragmented treatment algorithms for the elderly, injuries aren’t the only problems. Will the end-stage emphysema patient, diagnosed with pneumonia, be placed on a ventilator for more sustained misery? Will the patient bedridden and confused from multiple strokes benefit from a coronary stent if her chest pain is due to a heart attack? These are reasonable questions, both ethical and economic—especially since most Medicare dollars are spent in the last months of life.
It seems there is an endless tug of war when physicians are dealing with many of our elderly citizens, particularly those who can’t contribute their own opinions to the decision-making process. Largely because the government refuses to address tort reform, elderly patients’ frail bodies and hazy minds are endlessly subjected to tests and therapies that add little enjoyment to their lives and probably less to meaningfully extending those lives.
From the physician’s standpoint, caring for nursing-home patients is fraught with peril. Physicians face the possibility that they will violate some nebulous standard of care or endure litigation by the patient’s family. And they fear the misinterpretation of Medicare rules, which financially punish physicians and hospitals for “inappropriate” admissions, failure to follow their clinical guidelines, return visits for the same problem, and missed diagnoses. And there is the most appropriate fear of all: doing the wrong thing and causing suffering in another human being.
It is little wonder that nursing-home patients are so frequently sent to the hospital for even the slightest complaint. They are frail, osteoporotic, confused time bombs to their physicians and facility administrators, sadly juxtaposed to their position as vulnerable, weak, and often forgotten members of society.
Dementia aside, I have had the more competent patients from nursing homes say to me, “I didn’t want to come to the hospital, but they said I had to be seen!” And family members have complained, “We asked them not to put grandma in the ambulance. It only confuses her, but they said it was policy!”
Medicine is practiced in a labyrinth of uncertainty when it comes to treating these individuals. Partly born of corporate policies in nursing homes, partly born of a mentality by some that, “It doesn’t matter, Medicare will pay for it” (which is remarkably untrue), and partly from a deeply ingrained fear of litigation, we do too much that matters too little.
Lately I find myself doing less and reassuring families more. I often preface it all with: “If something is broken, do you want him to have surgery?” Or, “I know she had chest pain, but if it is a heart attack, how aggressive will we be?”
The answer is usually either, “No, I don’t want much done” or “I never really thought about it that way.” And if I can make the light come on in either the patient or the family, we all shake our heads at modern medicine, which is so often practiced by uncertain physicians genuflecting before ridiculous federal regulations and aggressive lawyers.
Pity we can’t simply learn to fix what we reasonably can, then allow some of our sick and injured elderly to sleep in comfortable beds rather than cry and languish on hard plastic backboards. When caring for the infirm aged, sometimes less is really more. Learning to do less, and being allowed to do less by all parties involved, is the real challenge.
Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.
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