“Doctor, please, he doesn’t want to leave the hospital alive.” Once it might have been a line in a skit, today it’s no joke. The elderly patient is in hospital for the sixth time this year. The cause, his wife synthesises, is “a tired brain”, punctured by strokes and subdued by dementia.
Absorbing her dejection, we move on to other patients admitted from residential care.
One complained of difficulty swallowing and was bundled into an ambulance. The saintly patience of a nurse coaxes food and drink into her, her sore throat explained by a dry mouth. Another had temporary chest discomfort and the briefest of histories reveals it to be muscular pain eased by simple analgesia. A third has fluid retention, relieved by an additional diuretic.
Careful minutes spent at each bedside quickly demonstrates a few things: one, nearly all their problems could have been addressed in the community and two, they hate being here.
A call to their family explodes another myth: far from pressuring the nursing home to send the patient to hospital, most advocated against it.
Now, many of these patients are stuck.
Multiple teams do their own thing. The flood of interventions, once unleashed, is impossible to tame.
The next several patients live alone or with an ageing spouse, or with a “child” nearing retirement. Their medical problems are minor, but they are teetering on the edge. They can’t climb stairs, are unsafe to drive, can’t remember their medications and need help with meals.
An alarming number of them are supporting a child with marital breakdown or mental illness. These patients don’t mind being in hospital where they feel safe, but their deepest wish is summed up by the man who says: “The best way you can help me is speed up my aged care package.”
He has waited six months. He could be waiting for another six.
“What are we doing for these patients?” asks a flummoxed medical student, probably thinking that the stories of doctors performing daily acts of heroism might just be fictional.
As if to compound his dismay, the phlebotomist asks if an unconscious dying patient really needs a blood test and a patient repeatedly wails, “Someone tell me why I am here.”
An annoyed nurse pulls me aside and begs me to stop the “crazy” tests that hurt patients. I tell her I would if I knew who was writing the orders but there is a different doctor each day.
A nurse sits in a corner with her head in her hands, a forlorn image that sums up the state of disillusioned providers.
Spend a few hours on the medical ward of any hospital and you feel the pulse of the entire healthcare system.
Beds are filled with the frail and elderly suffering conditions that are manageable but not curable. These patients spend a long time in hospital, which would be OK if they benefited, but many don’t. Instead, hospitalisation swaps one problem for another and leaves them deconditioned, isolated, and confused. Over-investigation does harm. Insomnia causes falls. The care feels impersonal.
The marvel of living longer is coupled with the inevitability of decline. Most of us can expect to live our final years on a merry-go-round of interventions with diminishing benefit.
At the same time, children die in emergency, women give birth on the road, and ambulance delays imperil lives.
It would be easy to misrepresent this as an argument for turning away from our elderly to free up hospital beds but that is beneath a decent society. Instead, we must meet our elderly patients where they are.
Many patients transferred from a facility to hospital could stay put if the facility had two things – competence and confidence.
Competence in the form of skilled professionals including doctors, nurses, and allied health staff. Where illness happens round the clock, access to help can’t be limited to a few hours. Confidence in the knowledge that while it is easy to summon an ambulance, this may not be the best idea.
What these patients need is a knowledgable doctor to take stock of the big picture and make a shared decision. For some, it will be admission to hospital, but for others it will be time-limited treatment or compassionate end-of-life care. Alas, this kind of doctor is disappearing because we like to hail GPs as the backbone of the system while breaking their back through flawed policies.
In place of the doctor who could provide care in the community at a fraction of the cost, I dispense costly and fragmented care in hospital where value for money is a sorry footnote. This care is reactive and detached from reality. The lack of communication is dangerous. To add insult to injury, the public purse is bleeding but complaints are rising.
This kind of healthcare makes no pragmatic, financial or moral sense.
The tired answer to healthcare woes is that no one has “a magic wand”. But what if the magic wand were reimagining healthcare as one ecosystem that faithfully serves the individual from birth to death?
Such a system would acknowledge that our needs evolve with age. It would prioritise prevention and early intervention for conditions, physical and psychological, that become costlier upon progression. It would recognise that surgery should be performed in hospital, but wounds can be dressed at home.
That funding Meals on Wheels is better than reversing malnutrition.
That home-based exercises are cheaper than fixing a fractured hip. Through improved education, it would restrain spending on futile care in the hospital at the end of life and redirect funds to community services.
It would send skilled nurses to community hubs so that hospitals were reserved for those who most needed it. And by replacing lip service with targeted investment, it would restore primary care to its rightful place so that no one dismissed one of the most important doctors a patient could have as “just a GP”.
